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_ SERVICE ODDER <br /> ASBURY ENVIRONMENTAL SERVICES, DRA FORA!NO.WOES004-A <br /> SERVICE ORDER NO. <br /> WORLD OIL <br /> ENVIRONMENTAL SERVICES~ <br /> S <br /> H +: , 1300 SOUTH SANTA FE,COMP I ON CA 40221 <br /> I . . <br /> P LOS ANGELES OFFICE SAN DIEGO OFFICE <br /> E 1-800-974-4445 1-800-748-5744 <br /> D <br /> T TRANSPORTER EPA CAD028277036 <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROU16F— I TRUCK# CONTACT NAME —ORDER BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE] CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> ���•�, <br /> PART# DESCRIPTION QTY UNIT PRICE xQTY P/U TOTAL <br /> TOTA L <br /> CASH RECD: CHECK#c <br /> 4 WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OlLs) STATE CODE 221 <br /> NDN-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> s DESIGNATEDTSDF: ; <br /> - <br /> ALTERNATETSDF: .. ,... .- _ _. _ , .... ,, <br /> DRUMS Pju: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE.CERTIFICATION(PLEASE CHECKTHE APPROPRIATE BOX) <br /> By signing below I hereby certiy that: <br /> (Waste oil generator/customer MUST check ONE of the fallOWing three boxes) <br /> 49*1)1 have not mixed any of the waste described above with any other hazardous yvaste,the totaE halide content is LESS than 1,000 ppm,and the waste does not contain any PCBs.I have complied with the requirements of <br /> the applicable CaUfarnia used oil management regulations to determine this is.true.l agree to accept the additional charges for the disposaf of this waste if the information I have provided aboutthis waste is incorrect <br /> =42 1 have not mixed any of the waste described above with any other hazardous waste,[he total haiide content is GREATER than 1.000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to VJohd oil Environmental Services to rebut the presumption that this waste was mixed evith other hazardous waste.I agree to accept the additional charges for the disposal of this <br /> waste if the information I have provided about this waste is incorrect <br /> CLI#3)This waste is from a tankwhich collects waste ail from household"do-it-yourself"fDIY)and/or conditionally exemptsmall quantity generator(CESQG)sources.To the best of my knowledge,the only waste off contained <br /> of this waste if the information 1 have provided about This waste is incorrect <br /> in my DWCESQG collection tank is sofey from DIY and/or CESQG sources.I have not mixed this waste oil with any ether hazardous waste or waste oil from ocher sources- es agree to accept the additional chargfor disposed <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> ,4091%t4)If I am a large quantity generator,l certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicabfe and that I have <br /> selected the practicable method of treatment,storage,or disposal currently available tome which minimfzes the present and future threat to human fife 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 I can afford. <br /> This individual signing in the space set forth below on behalf of Customer represents and warrants that hershe has the authority so bind Customer,that the forgoing descriptions of waste and materials are true and accurate <br /> as packaged,marked an,d fabefed,are ready for transportation in actordance with applicable state and federal regvlaCons;and that Customer shall abide and be bound by the Standard Terms and Conditions on the reverse <br /> side of rhis Servicp&der. <br /> j <br /> Customer Signature 1 F Date Dryer Signature Date <br /> Print Name Print DriglergKa'me �- <br />