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1187 VANDERBILT CIR. #2 <br /> CALItuRNIA COOLANT SERVICE MANTECA, CA 95337 <br /> "Your California Antifreeze Service Company" OFFICE: 209-239-5587 <br /> Transporter EPA#CARD00047167 FAX: 209-239-6316 <br /> SERVICE ORDER: 47504 <br /> IL- <br /> Custnmer <br /> r0adbaeet._Jffy Lube 2322(CRYKHE 21-702002 00014KHE) MANIFEST# <br /> 00 Kettlernan Lane/CHEROKEE <br /> .odt, CA 83240 <br /> 00-330-0000 <br /> PA*M.000102 045 Customer lk 1372/22 Contact;Steven Termed Net 30 f • !`��' <br /> CODE DESCRIPTION OTY UNIT PRICE AMOUNT <br /> 150 Frestone Prime 50/50 ArF 3D 5 . b D 12 o 00 <br /> 50 V ste Antifredze Pick Up <br /> Tank Serial Numbers: Non Taxable Sub Total 00 <br /> Taxable Sub Total <br /> Tax <br /> TOTAL DUE <br /> WASTE DISPOSAL INFORMATION <br /> ❑ NON-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 /> ❑ BANGO OIL,LLC: 22211 Bango Road•Fallen,NV 89406•NVR000080655•(775)852-2295 <br /> ❑ D/K DIXON: 7300 Chevron Way•Dixon,CA 95620•CAT080012602•(707)693-6008 <br /> ❑ RAMOS ENVIRONMENTAL: 1515 S.River Road-W.Sacramento,CA 95691 -CAD044003556•(916)371-5747 <br /> ❑ NU-SET INDUSTRIES: 977 South 700 West•Salt Lake City,UT 84104•UTD982589459•(801)977-0220 <br /> ❑ ALTERNATE TSDF: <br /> ❑ CFR: 33210 Western Avenue•Union City,CA 94587•(510)487-9277 <br /> (All 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 1 have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize the present and future threat to human <br /> life and the environment; Or,if I am a small quantity generator,I have made a good faith to minimize my waste generation and select the best waste management method that <br /> 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 HALIDES ARE LESS THAN 1000 P.P.M.;AND THAT THE WASTE DOES <br /> NOT CONTAIN ANY P.C.B'S. <br /> I FURTHER AGREE TO ACCEPT THE ADDITIONAL CHARGES FO LEGAL ISPOSAL THIS WASTE IS OVER 1000 P.P.M.TOTAL HALIDES,OR CONTAINS ANY P.C.B'S. <br /> 7 <br /> CLstomer Signature ate <br /> G <br /> LCA v) <br /> Print Name Print Driver's Name <br /> All returned checks are subject to a$15.00 Service Charge. <br /> Allamounts not paid within 30 days of invoice are subject to 1 1/2%interest per month,18%annually on unpaid balance. <br />