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1187 VANDERBILT CIR. #2 <br /> y + <br /> CAARNIA COOLANT SERVICE ApR d 3 IF <br /> �} CA, CA 95337 <br /> "Your California Antifreeze Service Company OFFICE: 209-239-5587 <br /> Transporter EPA#CAR000047167 FAx: 209-239-6316 <br /> SERVICE ORDER: 4,9549 <br /> Customer <br /> rand ac@_-.Jiffy►Lubs#2322 (ORYKHE 21-702602 00014KNE) MANIFEST# <br /> 00 Kettteman Lane/CHEROKEE <br /> odl, CA 85240 <br /> 19-330-0000 <br /> FA#M 000182 645 CU§t0f@F#,. 1372122 Contaet: Jamie Terms_ Not 30 Row. fi <br /> CODE DESCRIPTION CITY UNIT PRICE AMOUNT <br /> 50 F restone Prime 50150 AIF 5. (QQ 324.W <br /> 50 ste Antifreeze Pick Up �,� N �G <br /> Tank Serial Numbers: Non Taxable Sub Total B2_ <br /> Taxable Sub Total , <br /> Tax <br /> TOTAL DUE 32 V <br /> n <br /> WASTE DISPOSAL INFORMATION <br /> ❑ NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER)-NO PLACARDS REQUIRED- STATE CODE 221 <br /> OWRCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)*NO PLACARDS REQUIRED' STATE CODE 134 <br /> ❑ OTHER: <br /> ❑ DESIGNATEDTSDF: <br /> ❑ DEMENNO/KERDOON: 2000 N.Alameda Street-Compton,CA 90222-CAT080013352-(310)537-7100 <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 /> a'—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 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 /> I 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 /> t � p <br /> � '� � �� ` ,;is•� �"-`"=- _:�--.e-.---- -.._.-.:a !�'� <br /> Customer Signature Date Driver Signature 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 />