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FOR SI: IUICE GALL SERVICE CURDER FORM NO UVOE500A 618I18j
<br /> OFc ;ASBURY �N1lIRONMENTAC SER1lICES, DBA sERu,IGE,oRoeR No.;;
<br /> 1=800 727 2879
<br /> i
<br /> FOR ACCOUNfiING-CALL'*
<br /> 5�2 231 X650 „"
<br /> ENWIRONMENTAL SERVICES,
<br /> S � tTI # #k �€# yi 7300
<br /> "CHEVRON
<br /> N 1-800 727=2879
<br /> Pt � � s
<br /> Wut
<br /> 1NW WOALDOiLGORP-C,
<br /> E: TRANSPORTER EPA#GAD028277036 ` I 104
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<br /> CUSTO1lEE# � i'URiaASE ORDER# t'OUTE# TRUCK# CONTACT NA11lIE �' ORDER TAKEN �IALiDES
<br /> B
<br /> DATE E `IR D r ILL ofi LADINGI MANIFEST#
<br /> DATE ENTEREfl NEXT SERVICE DATE CtlSTOMER EPl1#
<br /> 77
<br /> rPpAT y .m bESCR#P°r!t}N� QTY" UNiT`PR10E QTY P/U :.TOTAL`
<br /> TOTAL
<br /> WASTE DISPC?SAL#NFORMATION
<br /> STATE CODE 221
<br /> ANO ` ICUIDUSED OILlMIXEfl OILS) , rt
<br /> p{ETHYLSNE GLYCOL SOLUTIONS)
<br /> STATE CODE
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<br /> 31
<br /> �LTEg ltr#" 31L `sirp § t
<br /> IAt1MS FACILITY SS777777,77 C
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<br /> x ti � 11yA${E CERTIFICATION (PLEASE CHECK 7HE`APPR.QPRIA'CE BQX)
<br /> �iT��erterator/customer MUSch
<br /> T eck ONE of,the,following three boxes
<br /> a of er-h zarilous waste thtotatfialide`content to LESS pan 1 Olio ppm and the waste dopes not contain any PCBs 1 haus"
<br /> . p 1d o= eyd@scc(bsGove wtth ny �t ,s e n this'Is tiue.a a res to accept the addltione)charges for the;disposai ot`this vasRe if
<br /> m ted; h t ag��g )�rit 6 *s applicable Caiifarnla usedotl management regulations to delerml 0 9
<br /> helntor�ipt o jtyt�prav1de�d ou ihl ,waste)s incorrect
<br /> the otal halide content Is GFEATEH.ihanl,'000 ppm,and the wa`sfe doeano-t'con#atn any PCBs i. "
<br /> ltavernot fixed any oflhe waste deilrriIf, above with"any o#her ha?a dous waste," ,"#",
<br /> n !,
<br /> 1 er docu tato to NXorld Oti EnvlronmentaCServ>ces to rebut the piosumptiontttat this waste was mixed with:other hazardous waste=I agree to accept the additional,
<br /> � � St Prop: 4
<br /> charggs for ttie2llaposal of 1 is�#e 1f the i>)t�ormel,�on 1 have provided abOtit ihls waste is Incorrect }
<br /> a`ndlor`condltlonaily exempt sn au*antity generator{CESQG)sources-To the best of my
<br /> - s e=# troltt a tank whicTr colleots.Ntasle;ol)from.household do it yo ( Y1,.,,,", , t"fixed thls wasteoli wlih°any o#herhezardous waste or Waste oil
<br /> k��k
<br /> nn i e nl waste ai)cbntalned in my t)IY%C,ESOG collection iank`ls'soley=ifom t51Y and/or CESCG sources.l have no m „,,.
<br /> rJ b'. t`sou ees1 agree to accept the addiilonal charges for disposal of,itila waste`if the lnformationi tiave`provided about this,waste is incorrect
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<br /> .> (A#I generators)customers MUST read the#o#lowingtext
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<br /> of vreste generated to the;degree 1 have.determined io be economiceliy«practicabte:and that 1 fiave selectetl ihe"
<br /> =� ice if rt�at a0e �o a�irtttlace#o reduce the ya m., Y
<br /> fe Fent sto a e;:or die-oral currently avaliabie,fo,mewpich minimizes the presenFand future threat to human lite and the emlronmeni
<br /> prerticab1_eithndv f ate p
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<br /> �` "w `' 't t he/she#Iasihe"authority to 61nticesfoma[#hot the,for9oing°de,acr>ptions of waste, ;"
<br /> ace satJotih below on?behaif otcastomer represents antl"warrants.,ha ,
<br /> This lhdty),uai signing It, p �, .>.-�.. ......:.. ... . tor,:trans ortationsin.apco�danca,wHh,applicable ate#e nd tedeia(regulations and#hal cuetoineE=shall abide..
<br /> r and mAtelfaJs��roitpe and ac%C teas packaged rharketl and labeled are ready, . n P a
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<br /> „` by the Stir dar`d Terme and Contlops on the revaise side of ihls Service Orilor
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<br /> us vieste.m8hifest,eiherslte spactfic or;consptidated)aresub act t6'an EPA Foe These tees cover the EPA pose throughtee and atlminlstratlen
<br /> }tanaassc�tese�e szvary baked on Manifest Type Applicable fees wliiappear on your`61111ng invofee. " w
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<br /> �� .� n� L1rtVer Sig �t �� batt?
<br /> 3
<br /> Rrinfi"Driver1Jarnt?
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