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CALFRNIA COOLANT SERVICE AN ECA, C B T CR. #2 <br /> MANTCACA 95337 <br /> F <br /> OFFICE: 209-239-5587 <br /> -Your California Antifreeze Service Company' <br /> Transporter EPA#CARD00047167 FAx: 209-239-6316 <br /> SERVICE ORDER: 49, ? .58 <br /> Customer <br /> roaldbsso -Jffy Lube#2322 (SR'YKHE 21-792602 00014KHE) MANIFEST# <br /> 00 Kettleman Lane!CHEROKEE <br /> odi,CA 95240 <br /> 09-339-0900 <br /> PSA#M 000182 646 Custom or* 1372122 Corte;Steven Term K. Net 30 Rep., • <br /> CODE DESCRIPTIONAMOUNT <br /> 50 F restone Prime 50/50 A/F J5• <br /> 50 Vste Aaltlf wat PI&Up <br /> Tank Serial Numbers: Non Taxable Sub Total 252 `[Jh0 <br /> Taxable Sub Total <br /> Tax <br /> TOTAL DUE 252 0 OD <br /> WASTE DISPOSAL INFORMATION <br /> ❑ NON-RCRA HAZARDOUS WASTE,LIQUID(OILY WATER)-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 /> ❑ 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 /> ❑ NU-SET INDUSTRIES: 977 South 700 West-Salt Lake City,UT 84104-UTD982589459-(801)977-0220 <br /> ❑ ALTERNATETSDF: <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. .B'S. <br /> i <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 />