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1187 VANDERBILT CIR. E -`IRONMENTAL SERVICES, Y-7. SERVICE ORDER//INVOICE: <br /> MANTECA, CA 9 CALIFORNIA COOLANT SERVICE 14680 <br /> OFFICE: 209-23 87 26 1012 Transporter EPA# CAR000171017 <br /> FAX: 209-239-6316 S3\- C�t�.D.O.T.0484667 D.T.S.C.#3544 CA#274461 DATE: <br /> SITE ADDRESSONMtv�1 �GES BILLING/MAILING ADDRESS <br /> Customer ��� �ZISE Customer <br /> 1amul Ay <br /> Elk grove, C'.A 95624 <br /> E.P.A. # Phoned 333 <br /> Additional Contacts: PAYMENT TERMS: NET 15 <br /> PRODUCT - SERVICE INFORMATION/PROPER SHIPPING DESCRIPTION <br /> 7 14 21 30 • 45 60 90 180 365 W/C WASTE MANIFEST NUMBER QUANTITY UNITS PRICE AMOUNT <br /> CODE <br /> At_ <br /> 1 Uv, <br /> i5 <br /> Empty Drums Provide J Remove J 1 A 1 1 A2 5g J 1 Og J 15g J 30g J 55g .i S P F <br /> Clor-D-Tect Q4000 Test Kit: Test J Pass❑ Fail J Generator Knowledge J PPM <br /> Transportation Charges/Additional Truck Time/Additional Labor/ LAB Packing/Site Cleaning <br /> Clean: Y N Labels Oil A/F UOF Oily Debris <br /> SERVICES REQUESTED BY TAX <br /> Accept " P. O. # TOTAL CHARGES: <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,marked,and <br /> labeled,and are in all respects in proper condition for transport by highway according to applicable state and national government regulations. If I am a large quantity generator,I certify that I have <br /> a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of <br /> treatment,storage,or disposal currently available to me which minimized the present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a <br /> good faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. All used oil from the generator listed above will be <br /> transported only to a facility permitted by the State of California to produce used oil into recycled oil OR a facility that is required to comply with Federal regulations applicable to the management of <br /> used all. All relevant information regarding known or suspected hazards associated with this waste has been disclosed. The customer agrees to pay reasonable costs and attorney fees incurred in the <br /> collection of this obligation. Venue for purposes of this obligation shall be in Solano County. I declare under penalty of perjury that the forgoing is true and correct. <br /> DISPOSAL/RECYCLING FACILTY: Collection Station Industrial Agriculture Government Marine Other Industrial Lubricating <br /> Oil Oil <br /> �"'�•'�:A r�'.:o':r;�.r.a r. V*jo.'.A 9003 rkmf,NV/3W3 YioawYrF(:A 9;W <br /> Hm.ep,til4UAI 5a:-A -tZrla Citi. <br /> 8U45:'t${37 'd7•;6Y•{1b/ 1T95)5531203 94111 <br /> NVT.430at Mluf <br /> Print Name Generator's Signature Driver's Signature <br /> I hereby certify that I have read and have the authority to bind the above listed generator to the terms on the reverse side of this form. <br /> State Law Requires that you keep this Receipt/Bill of Lading on file no less than 3 years. <br />