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1187 VANDERBILT CIR. #2 <br /> CALIr uRNIA COOLANT SERVICE MANTECA, CA 95337 <br /> "Your California Antifreeze Service Company" OFFICE: 209-239-5587 <br /> Transporter EPA#CAR000047167 FAx: 209-239-6316 <br /> SERVICE ORDER: e <br /> Customer 2 71 <br /> roadbase - ,�tfyLube 2322 {SRYKHE 21-792602 00014KHEI MANIFEST# r <br /> . 500 Kettleman Lame l CHEROKEE <br /> Lodi, CA 95240 <br /> 09-339-0900 <br /> �PA*moi.. 000 182 845 ClustomerA 1372122 Contact. Steven 7srnis, Net 30 §eta: <br /> CODE DESCRIPTIONAMOUNT <br /> 150 F restone Prime 50150 A(F <br /> 50 alste Antifreeze Pick Up <br /> Tank Serial Numbers: Non Taxable Sub Total <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 /> ❑ SAMOS ENVIRONMENTAL: 1515 S.River Road•W.Sacramento,CA 95691 •CAD044003556•(916)371-5747 <br /> ``,p",NU-SET INDUSTRIES: 977 South 700 West•Salt Lake City,UT 84104•UTD982589459•(801)977-0220 <br /> Z1ALTERNATETSDF: <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 I 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 /> '1 FURTHER AGREE TO ACCEPT THE ADDITIONAL CHARGES FOR LEGAL DISPOSAL IF THIS WASTE IS OVER 1000 P.P.M.TOTAL HALIDES,OR CONTAINS ANY P.C.B'S. <br /> J <br /> Customer SignatureD�— Driver Signature r Date <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 />