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1187 VANDERBILT CIR. #2 <br /> CALIFORNIA COOLANTSEROVICE MANTECA, CA,95337 <br /> "Your California Antifreeze Service Company" OFFICE: 209-239-5587 <br /> Transporter EPA#CAR000047167 FAx: 209-239-6316 <br /> SERVICE ORDER: 67533 <br /> a <br /> IdImlain Valles Expres(towble 9.251/o) MANIFEST# <br /> 1419EewmerAvef �✓ ��� <br /> CA 95336 <br /> 249-823-2118 <br /> ZPA 1D 0 CA 415 560 Cutcmer# 1826 CiinitfictDaia SIM-1121 TmwiL PCWReqairedNe <br /> 2.teff Atal'' <br /> •eMENEM® s e <br /> 120 CC&500 ALE <br /> 454 WageAmptiftwo Pick U15 <br /> UOQ' Tsed Oal&GawlimFifltes <br /> U A3 <br /> MR <br /> Tank Serial Numbers: Non Taxable Sub Total <br /> Taxable Sub Total <br /> Tax <br /> TOTAL DUE <br /> WASTE DISPOSAL INFORMATION <br /> 'VIANON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OIL)"NO PLACARDS REQUIRED` STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)-NO PLACARDS REQUIRED' STATE CODE 134 <br /> ❑ OTHER: <br /> ❑ DESIGNATEDTSDF: <br /> ❑ EVERGREEN OIL,INC.: 6880 Smith Avenue•Newark,CA •CAD980887418•(510)795-4400 <br /> ❑ THE L1.F.adj,�DS: 655 South Stanford Way•Sparks,NV 89431•NVD982510711•(775)219-7396 <br /> D/K DIXIs�"PI�O Chevron Way•Dixon,CA 95620•CAT080012602•(707)693-6008 <br /> AMOS ENVIRONMENTAL: 1515 S.River Road•W.Sacramento,CA 95691•CADD44003556•(916)371-5747 <br /> ❑ NU-SET INDUSTRIES: 977 South 700 West•Salt Lake City,UT 84104•UTD982589459•(801)977-0220 <br /> AR 27 Western3Avenue• %.n i y,CA 94587•(510)487-9277 <br /> (AIB Generators/Customers MUST read the following text.) <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize the present <br /> and future threat to human life and the environment; Or,if I am a small quantity generator,1 have made a good faith o minimize my waste generation and select the <br /> best waste management method that is available to me that I can afford. <br /> '1 HEREBY CERTIFY THAT I HAVE NOT MIXED THIS WASTE WITH ANY OTHER WASTE,THAT THE TOTAL H 1 ES ARE LE THAN 1000 P.P.M.;AND THAT THE WASTE DOES <br /> NOT CONTAIN ANY P.C.B'S. <br /> "1 FURTHER AGREE TO CCEPT THE ADDITIONAL CHARGES FOR LEG DISP AL IF THIS WASTE IS OV 1000 P.P.M. OTA HALIDES,OR CONTAINS ANY RC.B'S. <br /> Customer Sig ture D e Driver Si ure Date <br /> AN <br /> Print Name Prin,Driver's me <br /> All returned checks are subject to a$15.00 Service Charge. <br /> " All amounts not paid within 30 days of invoice are subject to 1 1/2%interest per month,18%annually on unpaid balance. <br /> If account is forwarded to collections and or an attorney customer will be responsible for all collection and or attorney fees. <br />