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FOR SERVICE CALL: SERVICE ORDER <br /> PARLIER ASBURY ENVIRONMENTAL SERVICES, DBA FORM Nb.WOES004-D (1/17) <br /> 559-498-0240 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 X, <br /> WORLD OIL <br /> ENVIRONMENTAL SERVICES- <br /> H 14287 EAST MANNING AVE,PARUER CA 93648 <br /> 1-559-498-0240 <br /> P WWW.WORLDOILCORP.COM <br /> �Tf <br /> D <br /> T TRANSPORTER EPA#,CAD028277036 <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDERTAKEN BY HALIDES <br /> fi <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST <br /> PART 4 DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> j i>') <br /> 1S. <br /> -1 <br /> "]t 21 <br /> &�&k al TOTA L <br /> CASH l CHECK I=t <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 /> DESIGNATEl <br /> ALTERNATETSDF: <br /> DRUMS P/U:- EMPTY DRUMS: FACILITY- BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECKTHE APPROPRIATE BOX) <br /> By signing below herehy certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> E=#I)Ihave not mixed any of the waste described above with any other hazardous waste,the total halide content i5 LE55than 1,000 ppm,and the waste does not contain any PCBs.I have compiled with the requirements of <br /> the applicable California used oil management regulations to determine this is true,I agree to accept the additional charges for the disposal of this waste If the information I have provided about this waste Is incorrect <br /> =,12 1have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCEis,I <br /> have provided proper documentation to World OR Environmental Services M rebut the pre5umption that this waste was mixed with other hazardous waste.I agree to accept the additional charges for the 6isposai of this <br /> waste if the Information I have provided about this waste Is incorrect <br /> =#3)This waste is from a tank which collects waste oil from household'do-Tt-yourself"(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my knowledge,the only waste oil contained <br /> in my DIY!CESOG collection tank is soley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal <br /> ofthis waste if the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> =1#4)Ifl am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity ofwaste generated to the degree I have determined to be economically practicable and that I have <br /> selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment:Or,if I am a small quantity generator,I <br /> have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me that E can afford. <br /> This individual signing in the space set forth below on behalf of Customer represents and warrants that he/she has the authority to bind Customer,that the forgoing descriptions of and materials are true and accurate <br /> as packaged,marked and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that Customer shall abide and he bound by the Standard Terms and Conditions on the reverse <br /> side cftl Service Order. <br /> Custo M� er Signature Date Driver Signature Date <br /> " <br /> Print Name PrintDrivers Name <br />