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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA FORM NO.WOES004-B <br /> 1-800-7-ASBURYO SERVICE ORDER NO. <br /> PARL/ER <br /> 559-498-0240 <br /> CRIco WORLD OIL <br /> 800-733-9043 <br /> ENVIRONMENTAL SERVICES. <br /> s 1300 SOUTH SANTA FE,COMPTON CA 90221 <br /> H <br /> I LOS ANGELES OFFICE <br /> P 1-800-974-4495 <br /> E <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDERTAKENBY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADINGIMANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASHREC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE_ <br /> OTHER: — <br /> DESIGNATEDT5DF: <br /> ALTERNATE TSDF: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By slgrslrg below I hereby certify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Oa I I I neve nos mound any 0 the waste described abpve wish any odun haeudous wanethe total halide content is LESS than 1.0013 ppm.and the waste does nor contain mull I him complied with the requbament,of <br /> theapplhap,,Call(om4 used oil mane,hous ltegulatdns to determine this Is true,I agree or accept the addllimal charges for the disposal of this wase11 theinformation I have pm.ded about this waste Is Incorrect <br /> Oa]1 have Mr mixed any of the waste described above wIM my other haseedous waste,the total halide content is GREATER than 1.009 ppm,and the waste does not contain any Klrx I <br /> have provided proper doeutne lifion to World 011 EtMro mentel Services to rebut rhe presumption that this waste was mixed warn other M1aWdous wave.I agree to accept me vireposoi chergn for the desposal of this <br /> waste if the Information I neve movided about this waste Is Incorrect <br /> Oa31 Thls waste it from a tank which collect,waste oil from hausehold'do-Ipyou vil'fD%1 fill conditionally exempt small quunthy giv actor(CESOG)sources.To the best of my knowledge,the only waste oil conmned <br /> In my M!CESOG collection tank is soley from off and/or CESOG sourtea 1 hon not mired this wane oil with any other,M1aiardous waste or waste W film other smites.I agree to accent the additional charges for disposal <br /> of this waste if the Information I have provided about this waste is Imonect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> =041 If I sm a large gwmiry generator.I cm116 chit I have a program in piece ro reduce the volume and toxmty d waste generated to the dingiest love determined to be«orom¢d1Y prankahle and that I have <br /> selected the practicable method of treatment stexage,or disposal cupend,available to me which mmlmdes the present and future threat to human tire aid the envimnmalll Or.if I am a small quantity gmenstot l <br /> have made a good faith effort to minimlee my waste gampardm and seal the best waste management method that Is available to me that I can Afford. <br /> This Individual signing in the space set forth helow on behalf d Cusronwr represent,and warrants than he/she has she authority to bind Cusmma.that the lorgdng descriptors of waste and materale are true and accurate <br /> it,fKK kaged.narked ams abNed,—ready Inr,ensporrndoo to xmrdanm with imputable sur and federal mgulanms,and that Customer shell aMde and be hound b/the Standard Tams and Conditions on the reverse <br /> sloe of this Service Orde,. <br /> Customer Signature Date Driver Signature Date <br /> .,-t-•.r-__ Print Drivers Name <br />