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FOR SERVICE dAL.L,:' - SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DSA FORM NO.WOES004-B <br /> 1-800-7-ASBURY "' SERVICE ORDER NO. <br /> PARLIFR <br /> 559-498-0240 <br /> CHICO <br /> 800-733-9043 WORLD OIL <br /> ENVIRONMENTAL. SERVICES., <br /> ri 7300 SOUTH SANTA FE,COMPTON CA 90221 <br /> P LOS ANGELES OFFICE <br /> t 7-800-974-4495 <br /> r TRANSPORTER EPA#CAD028277036 <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDERTAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> ��.. <br /> � r <br /> [ �it; #Yom.: •'� � ""� '� �..�,. <br /> —..«..�:. .,mom � 3 •se'�a.' <br /> PART-#--- DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> t <br /> i <br /> s <br /> IOTA L <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 /> DESIGNATEpTSDF: . <br /> ALTERNATE TSDF: <br /> Li <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: SSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 11 I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,006 ppm,and the waste does not contairt any PCSs.I have complied 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,ha disposal of this waste if the information I have provided about this waste is incorrect <br /> =92 f have not mixed any ofthe waste described above with any other hazardous waste,the total halide centent is GREATER than 7,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to World Oil Envtronmental services to rebut the presumption that this waste was mixed with other hazardous wase-I agree to acceptthe additional charges for the disposal of this <br /> waste ifthe;nformation i have provided about this waste is incorrect <br /> O43)This waste is from a tank which collects waste oil from hous.hold"do-it-yourself'iDY,and/or conditionally exempt small quantity generator(CESQG)sourcesTothe best of my knowledge,the only waste oif contained <br /> in my DIY!rESQCs coi;ectioc tank is.soley from D€Y and/or CESOG sources.I have not mixed this waste ed with any other hzzardovs waste or waste oil from other sources.l agree to adept the additional charges for disposal <br /> of this waste if the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and cheep the associated box.) <br /> C401114)If I am a large quantity generator,i certify that 1 have a program in place to redice the volume and toxicity of waste generated to the degree 1 have determined to he economically practicableand 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;0,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 i can afford. <br /> This individual signing in the space set forth below an behalf af.Cistomer represents and warrants that he/she has the authority to bind Customer,that the forgoing descriptions of waste and materials ate true and accurate <br /> as packaged,marked and labeled,are ready for transportation in accordanre with applicable state and federal regulations,and that Customer shall abide and be bound by the Standard Terms and Conditions on the reverse <br /> Side of this Servite Order., i <br /> Customer Signature Date Driver S'sgr-fatu, Date <br /> Print Name PrimPrint-I;0�rs NaName r <br />