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CUSTOMER # PURCHASE ORDER # `i
<br />DATE REQt7iRED, . ".,. DATEEM�RED`'- r `' .'
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<br />WASTE DISPO,SAL.IN�ORMATION " .
<br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIUMIXED O►LS) STATE CODE 2�1
<br />NON-RCRA HAZARDOUS WASTEr LIQUID (ETHYLENE GLYCOL.SOLUTlONS) STATE CODE ` `i= �, ,r r
<br />OTHER. = t° ,, � r _ ,_ ,
<br />DESIGNATEC)`i'SI�F: �� r' '' ��'
<br />ALTERNATETSDF:
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<br />DRUI�IS �'!U: Ei4itJTY i7RUlutSf ,� FACII.iTY I�SC t € r
<br />• .• GENERATOR WASTE CERTIFICATION (PLEASE CHECKTHE APPROPRIATE BOX)
<br />By signing below! hereby certify that: _ , _ r s
<br />(Waste,oi# generatorlcustorrier M,USfi�check ONE of the fol#owtt�g three._boxes)�' ,;; � . �� , ...�
<br />Di; i) I have not mixed any of the waste described above with any other hazardotis waste, the fetal halide content Is LE55 than 1,006 ppm, and the waste dpes not contain any PCBs.I have complied r)ith ttte regu(rements of `
<br />the applicable California used oil managementregulations to determinathis istru�. iagree toaccept the additional charges for the disposal of this waste If the information i have provided aboarthts waste is inmlrect ,
<br />Or♦21 have not mixed any of the waste described above with aqy other hazardous waste, the total halide [on�tent is GREATER than 1,006 ppm, and the waste does not contain any PCBs:I �. ,
<br />have provided properdocumentatlontoworldOilEnvironmentalservicestorebutthepre<.umptionThatthiswastewasmixedwithotherhazardouswaste:iagreetoaccepttheaddtrionaichargesforthedisposalofthis
<br />waste if the information I have provided about this waste is Incorrect ' `- '^^ - � ` � � � � �' ' ` � `' � ' ' `"
<br />� 8} this W4�!.te is 3}om a tnnk�arh ci�.cv, t'[ts wt,t� till frau: Fso.tschoid's:u�il pqur:cit'Ci�t3 Sndltl,.Caod,uorlally Laeras;rt lltt.t�l tjuunsity ,{ tae;atc?4 t�i:�C'Ci) scir{fts. Ta fhr.tixzt z t my kr�niedr}c t1t�_itni} v a41� �iltatrtaenri
<br />ire rrry rJn'f GESGCa t;oiRrii n t tfsk iS sbiep ttoitr pi'Yantltot tBSQG sprarca3 i have nrst'mi=rd that. vtnste tt,t �irithtiny nthet iiax*ttdusrt :vas;:f gr sux3tr: rsd imnt utlsr snnrr�s t agra _ to, crept tisr'11Eiiki;,ts,E th�rr�ysitiat �d pv�d!
<br />of this wattt<,f the in'nmrtt.orifl is�ve praact�ied {i�tnrtthii yr x;e js irrorr�t
<br />C_ir7•#itft;y:3r?tatt{rgr fj,itygt*herttt�
<br />se(t:cted �r:{:racti<a fein"rt3u�c#attr
<br />have uta � agcod.fsi h`effort to rgfgi
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<br />This indtvi uai tgning It the ;pare se
<br />as paik�g d, marked a t�f labeled, are
<br />side ofthi.5srvlcstlyd=
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<br />Print Naive
<br />(A## r�enera arse custprner� M�15T read# tt�e �o##Ovvir�g text and �}�e�k the a�s�c�ated .box �
<br />r 7 cat�ify t#;�t i ' ve aibym iri�}ta�e itr reduce tf{�'+tais+ni�,an� tpx�ciiyxtf tvA3tC gi�+si<rat�s! 3o t1;si s:t<y��� 1 itfrl� dttt.murt�t tv Lg ticarramlc tIy tr stis4v4ts &rsi t's,.t i h t}c ,
<br />;<ir,t&tit*?t5r� rrdigpos�lcyttnrstiyaw�u7abt�-iffmer'h�h�mmimizeit�pn«ni,t);}r�ftt£turtE?;�nittzl+uhiatfUrQ�7J.dt(��stn+7tc?ts:nejtL-4r4iitaM.t;tn�ltr{,h�tpr,tygrn�ntbr# _
<br />"ze my,waste rtersit>rt and select the belt vrasie management method that Is available to me„that Lcan afford..
<br />t rEh hetow on half of Customer represents and warrants that helshe has the authority to bind Customer, that the forgoing descriptions of waste and materials am true and accurate
<br />r dyfor trettsr nation in accordance with applicable state and federal regulations; and that Customer shall abide and be bound by the Standard Terms and Conduions on the reverse
<br />Date Driver�i �18tur
<br />Print Drivers Name
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