|
---- ----- -f`_ A- -
<br /> DIXONFOR
<br /> FIC CALL- SERVICE ORDER •I , . , iL
<br /> IXON OFFICE FORM NO WOESODA-B &10) w•f '1w'0..;,
<br /> a-90a]2T-2elg ASBURY ENVIRONMENTAL SERVICES, DBA FERVICuoROC" No. 1 '
<br /> FOR ACCOUNTING CALL: ty0 `
<br /> WORLD OIL
<br /> ENVIRONMENTAL SERVICES - �" -
<br /> lJenCHLYRONWAY. DIXON, CAeya2p
<br /> live 777-�117n
<br /> VvWW.WORLOOILCORP.COM r •}, a/'
<br /> ITRANSPORTER EPA a CADOn2Tl006 d j f .t
<br /> a It 3N1IT:liy ! .
<br /> I CUS70M1fER d to
<br /> PURCHASE ORDER d ROUTE d TRUCK d CONTACT NAME
<br /> ORDER TAKEN BY MAUDES T�""��" f S ' + T
<br /> III ry3y {E . 5l . ,,. .
<br /> DATE REQUIRED DATE ENTERED t + 7r t {Yr
<br /> NEXT SERVICE DATE CUST01.tER EPA s BILL of LADMW MANIFEST o
<br /> 1AKURDOUS WASTE ;� s ���1��� ll.
<br /> PARTY DESCRIPTION STATE AND FEDERAL LAWS PROHIBR IMPROPER DISPOSAL Z'r :. �• -2 yl
<br /> CITY UNIT PRICE 07Y PN TOTAL Y •L{[ t
<br /> IF FDUNO. CONl RC1TNL NFANFCiPoUCEORPUBUL SAFER AUIIIORIIY INE U fXVIgONNFNIAt / it ) T S '{ PSL
<br /> VROTtEll &GENCT ONTiI[ [AIIFOkNNOEPAg1MFK1 OF TOXIC SUBSTANCI CONTROL n I•�r ' Y� G Ali 5'�tA `� �M
<br /> GENERATOR INFORMATION- ` w Y .+ � 'F S' 1
<br /> eAA
<br /> I ADDRESS r PHONE �. / 04110 1 :3
<br /> yy`'�
<br /> tin STATE ` by / \; f [[.1. al'i't I •;4 f L +.FY
<br /> .: LP NO MANIFEST f i ( ( Tri ll f J l A, jjFW fY,
<br /> TOTAL / DOCUMENT NO 1 J (J iRMI )• ry>, q' Fq
<br /> ASH RECD: EPA WASTE CA ' ASTE ACCUMULATION / ylIllk,PllllllIIli51M.
<br /> =;E ,,�aS5 . ° •+
<br /> 1 CHECK Y_ / NO • , NO s1ARt pATC I v ;: jd-
<br /> ll
<br /> CONIENTS C0Mop511lON a a rTT`'
<br /> WASTE DISPOSAL INFORMATION / Y ' F - r � ' t��
<br /> NON•RCRA HAZARDOUS WASTE, LIQUID USED OIL/MIXED OILS STATE CODE 22'1 PNYSICALSTATE: NAiARD0U5 PRDPERRES: ❑ FIAMMAREE O 10xIC Ip�;� r 1 i �, ,)NON-RCRA HAZARDOUS WAS7E, LIQUID (ETHYLENE GLYCOL SOLl1TIONS) STATE CODE_ l] SOLID CJLIODDO ❑ CORROSIVE DREACTIVE ❑ OTHER ':'rF I i y�}r'Tj� * -yy1- 'r ! �'•T{j �+,jz� k
<br /> OTHER: p��c , >•''```IaL('%A 4or, k* ' i is
<br /> DESIGNATED TSDF: + {t' ' r T NN .� C . Y S T
<br /> I S 11ff rIh , yh
<br /> V
<br /> loss
<br /> ALTERNATE TSDF: h > i Jr 4
<br /> W. .WnN: I ,.YIh , . N mIN in (,11 y� �k � �;` f � NO
<br /> �� "+ gid
<br /> T / M.
<br /> 4 ilTl.{h Ar,r, Lt r
<br /> DRUMS PIU: EMPTY DRUMS: FACILITY; BSC , HANDLE WITH (CARE . L4 �x�I, � _ '� . t `Y� , , T,•
<br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) a j� �
<br /> yr ? 1INT a q\ '"^I "T t9 I . / ib F R Lr. - ', :.� �►<
<br /> By signing aWa* InaraDy certrry mel �l L
<br /> (Waste oil generator/customer MUST check ONE of the following three boxes) . .
<br /> ''"at) f have not mixed any of the waste dasCnbed above with any other hazardous waste, the total halide Content is LESS than 1 ,000 ppm and the waste does not contain any Pces. I neve 1 , �' E-
<br /> compiled with the requirements of Me applicable California Lead all MrWL;Nmont regulauOrI0 to didermino this IS true l agree lO Accept the additional charges for Ne disposal of into Mstt 11 �', 5N• i '
<br /> the Information l have provided about into *saw is incorrect 1 .
<br /> " . I
<br /> Wkid F, NIL L
<br /> r 1 IN K rY.
<br /> Rlnave not intrad dnY of me waste destrtbotl o00ve with any othdt hernrdous waste, the TOM[ halide content is GREATER man 1,000 pOm, Azad the Meto does nal contain any PCBa. I r 1 }y', .af
<br /> hdve p vidW proper documentation Io World Oil EOVlronmenlal Services to rebut the presumption that MIS waste was mixed with other hazardous waste I agree to nettle the additional ,r r . J J I A � y I IN
<br /> a�'}F� ,
<br /> :hargm for the disposal or this waste if me to formation l have provided about this waste is Incorrect f 0-k l~ �� , J ( h % N C 9
<br /> Y `
<br /> • ` ^
<br /> A) TNv *este is from a tank wNlcn eolloels *ossa all From household 'do-Il-younalf (DIY) andbreondlllondlty aaampt small quantity generator (CESDG) soureoa. TptM beatot my till •t tt� • .I Mr/� ;S..�E` ,�
<br /> mvledge, the only waste oil contalnaa In my DIY/ CESOD Collection tank U coley from DIY sndfor CESOG sources. I have not mixed trill Wasta all with any other h=MO" Waste or wgta r� C' Aj• 'i
<br /> JIN
<br /> Pmother SOUMO . l Agrad to acct Me additional charges lot disposal of ata wash 11 In b Info Mellon l have Prov idea about this Mate Is lnConict ' + , ( K' y ' i• 1r rZ L+p
<br /> (ATI generators/ customers MUST read the following text t /+ Not
<br /> Ilry Nal I have a program In place to reduce the volume and toxicity of waste gorlerniod b the degree I have determined to be economicaily Practicable and that I have scleCaa mo t XL e:• w - '
<br /> hnIble metrias of treatment. storage, or dlopoul Currently available to me which minimized me present and future ramal to human life and the environment f IN, 11-
<br /> 5L �Ty t e m L. y�yJ�
<br /> dlvidual signing In 00 space "I 10nh below On behalf of customer represents; and warenta that World hew the authority to bind customer, that the forgoing descriptions a1 Mats 1 ft .t
<br /> vtarlifs am true and accurate as packaged, marked, and labeled, aro toady for transportation In accordance with applicable stale and federal ray Iatlons, and that customer shelf ab t.4 t
<br /> 1 Standard Terms and Conelrfons an ms reverse aide at this Service Order. �#1 , II Nor IN e N . . .rwv'�
<br /> i r ♦ \ 1
<br /> IN
<br /> e Crdara RtN en asaoUated lMnrdoua woes* manllul (altnar aIle apeUlic ar comolidalad) ora aubjetl to en EPA Fee. These tees cover me EPA passmrougn ICo and eaminiettnt' : L
<br /> !Mam!esf Pr4JM• Ttledslees vary basad on Mail type. Applicable Icas will appear on your billing invoice - . ',
<br /> � r Y
<br /> 44
<br /> mer Signature Date Driver Signature Date Y
<br /> IN
<br /> lame Print Driver Name J t _
<br />
|