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ES004=E€t'�(1 /17)
<br />r ,, t't�K ;�- �� ,,��, t;-�L3��LjS:idiF'i_€iJs�7.,:" ' .,,$ - �,.£-,` r s:}•f � ,:tits � s.stnts:s;€�i�.e• <�s;s-r14? ,�a+a,rsk
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<br />i -Fi ?-ie'' tx 3"` '# �cY s"e': .4F "`n r;...•„+ �.. ,d! a i;. d S -Y 1 df �+. £r 3h3� i.k> =,a"2i <[ rra��¥'c > a : 'fit€
<br />`o � - �.T ra r zr,;cs a ,� } r,? v F..- # sr S f..� aNg £�- ti' � s x x ”' oy � !�'�r�-J.r� � . 4
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<br />� 1 � 7 $"" £ k � � � ._S s ,:> P i =. F 3` y# `> t � k. � z J "'� i Y .: �> :[:
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<br />- WASTE DISPOSAL INFORMATION' `
<br />t �
<br />NON-RCRA-HAZARDOUS WASTE, LIQUID (USED 01L/MIXED"0115) ' ` ` ` "'•STATE"CODE'221 ��� '' `�� � '
<br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE�GLYCOL SOLUTIONS) STATE CODE
<br />9T,HER: .. =
<br />`' DESIGNATED TSDF:'' � � ,+ ` t = � x �� irs.'n �+ � � �'
<br />--�----�ia�i.--f;`-t`—��r"d���` �iz`?`> w�~�`a�����t°.r,.�r �irt:r ��� �4T�=)€#�',`'''�����:0'
<br />ALTERNATETSDF:
<br />DRUMS�P/U. EMRT,,Y. DRUMS: %t1CCC.lTY• ` � B_S,C '
<br />�,._. .,, � ... v .. ,
<br />,t �` � GENERATOR WASTE CERTIFICATION (PLEASE CHECK.THE-APPROPRIATE BOX) `' `
<br />.By signingbelow I hereby certify that:
<br />�.� _ � .: tV��s��'c�si cjener`at€it`IeU�tt�r�e� MLiS' �I» �Nir til" ��€�.f`nIIOWi� ti�t�e'�axe�}:`: $.
<br />5 ^ � - res : { A ,. nrx edntarnar, i'E$S:iTu1�e com lied rilth the requirements of
<br />ntUttavinoEmrxedanyofthetvasted.-*,cry+ti}a�*�vv�Urit€}snycth�rh�art,dotts��, le t1t,,tc#a��hMide'carntat�l£S3€lranS,Qikt i m'sttl4}'eV�stedrtrr,, p p
<br />�apphtableCaVfomiausedmlmanarjintenirc-gulagcnstt�d<iertn,re[hrsr&irrfe.txruc�tt3��,cnpftheatldltfott�Ith.,tpr3,irtthrilinptrxaissittiJsrra�tri#S?SelhtomtiEiWnthaa�ptozi�edabout.hr,tzasteismcorrect
<br />px21 have not mired any cf the rrgste described above rritH any other hazardous waste, the total halide content is GREATER than 1,004 ppm, and the vraste does not,tontain any PC©s, t
<br />'have provided proper dccumaxation to tVorld Oil Environmcn[al Services to rebut the presumpt;cn that this waste was mixed :rich other hazardou vaste.l agree to accept the additional charges for the disposal of this
<br />' � yv tste tf the infermatiori h rve provided about this•rraste iz Incorrect "
<br />Q,3}Thi�s waste 1s tram a.tankwhichCollects waste oil rrom Household "dgit-yourself(DlYJ and/or conditionahy.ezempt small quantity generator�€CESQG) sources, to .hebest of my knd.vlydge, the onlywaste oil contained
<br />in my pIYICHSQG coliccUen tank is:3oteylrom'DtY and/or CES4sG<_vurtes�i Lhavenotmixed this waste oil :vith'ariy ether hazardous tivaste or vraste oitfrom other sources�Cagree to°accept the additional charges. for dispo;Sl
<br />of this vette if `the information I have provided about this waste is incorect -
<br />( c�enerator�/ c€�stnmPrs MUST.read the following text and check the associated box)
<br />!'�a j�;1 yrh =i latyi•{ji3antity+3•g4ysJtur. t 4r iiy lHat I Imve u t7iu�(am.l t.Ia« «r r�.,a�e Ut •olirmr and tc:Icity of armta generated to the degree f Hnve deteni7ined to he ecpnrmically p,a..t _,.Slc and that I hoee
<br />Ti++ rrlj�rvldual si:gt i r{} in
<br />as tnc?aS�kJ. tisartgt3 and
<br />r
<br />Print Name
<br />�sei fa
<br />forego; nrdispos at aur��ntty available to me which ramunizes the present and future threacto human fife and the environment• Vr,if; am a small quandtyueocrator,l
<br />raste generatirn and :elect the be;tcvsste rnaragcment imz(hod that is awilahl? tomeihat I can affwc#, -
<br />oov nn behalf nFru.tomer reprs^rats and rarrants thot he/she has cite authority to bind Cusromer, that the forooing descriptions ofnraste and rmai�riah arc true and accurate
<br />transpvriatiun in .+ccorrlance s.ith appl.,able nate and fedrral4egufniicns,and that Customer shall abide and Le bound by the 5[andarri Tc rrns ancj,C.�rrdittnns on the reverse
<br />` Date jf 1
<br />Print D
<br />ame
<br />,.
<br />r ,, t't�K ;�- �� ,,��, t;-�L3��LjS:idiF'i_€iJs�7.,:" ' .,,$ - �,.£-,` r s:}•f � ,:tits � s.stnts:s;€�i�.e• <�s;s-r14? ,�a+a,rsk
<br />'.�,*. ~,•:ate-ri° r «x ph f �� }gy�ppp ;. p�»! � -i J xi zr ,r � c r}s5 t .ir... r� -�sr., �r- 3y Bart rra �a r
<br />yA y"'� �Y '��,S�T-�iPi��C" �' ' y r } �.: � 'x Q � r«a""� t �d �S� �,+�� $? tx C � � zr
<br />� �
<br />i -Fi ?-ie'' tx 3"` '# �cY s"e': .4F "`n r;...•„+ �.. ,d! a i;. d S -Y 1 df �+. £r 3h3� i.k> =,a"2i <[ rra��¥'c > a : 'fit€
<br />`o � - �.T ra r zr,;cs a ,� } r,? v F..- # sr S f..� aNg £�- ti' � s x x ”' oy � !�'�r�-J.r� � . 4
<br />i•
<br />� 1 � 7 $"" £ k � � � ._S s ,:> P i =. F 3` y# `> t � k. � z J "'� i Y .: �> :[:
<br />Y
<br />A'£ S B -.Y °# � ... 3-w➢ls ? S Ra xf.I3 i 3,1 4 r� -i ...X -✓ 'S k! 4 • "��5� } ".a r .r ✓ 23 .'L'a, 7
<br />t � C31;;t1i '
<br />r a _ � >� r�� �,�
<br />{ r: ,i
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<br />v r� � � � 1 � �, � , � � '�'TOTAL�;,:
<br />,.
<br />k,, . t. „ -
<br />�- .,
<br />... .
<br />.,
<br />/f��t�'• t�/� r� /+[�� }� u
<br />� -
<br />- WASTE DISPOSAL INFORMATION' `
<br />t �
<br />NON-RCRA-HAZARDOUS WASTE, LIQUID (USED 01L/MIXED"0115) ' ` ` ` "'•STATE"CODE'221 ��� '' `�� � '
<br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE�GLYCOL SOLUTIONS) STATE CODE
<br />9T,HER: .. =
<br />`' DESIGNATED TSDF:'' � � ,+ ` t = � x �� irs.'n �+ � � �'
<br />--�----�ia�i.--f;`-t`—��r"d���` �iz`?`> w�~�`a�����t°.r,.�r �irt:r ��� �4T�=)€#�',`'''�����:0'
<br />ALTERNATETSDF:
<br />DRUMS�P/U. EMRT,,Y. DRUMS: %t1CCC.lTY• ` � B_S,C '
<br />�,._. .,, � ... v .. ,
<br />,t �` � GENERATOR WASTE CERTIFICATION (PLEASE CHECK.THE-APPROPRIATE BOX) `' `
<br />.By signingbelow I hereby certify that:
<br />�.� _ � .: tV��s��'c�si cjener`at€it`IeU�tt�r�e� MLiS' �I» �Nir til" ��€�.f`nIIOWi� ti�t�e'�axe�}:`: $.
<br />5 ^ � - res : { A ,. nrx edntarnar, i'E$S:iTu1�e com lied rilth the requirements of
<br />ntUttavinoEmrxedanyofthetvasted.-*,cry+ti}a�*�vv�Urit€}snycth�rh�art,dotts��, le t1t,,tc#a��hMide'carntat�l£S3€lranS,Qikt i m'sttl4}'eV�stedrtrr,, p p
<br />�apphtableCaVfomiausedmlmanarjintenirc-gulagcnstt�d<iertn,re[hrsr&irrfe.txruc�tt3��,cnpftheatldltfott�Ith.,tpr3,irtthrilinptrxaissittiJsrra�tri#S?SelhtomtiEiWnthaa�ptozi�edabout.hr,tzasteismcorrect
<br />px21 have not mired any cf the rrgste described above rritH any other hazardous waste, the total halide content is GREATER than 1,004 ppm, and the vraste does not,tontain any PC©s, t
<br />'have provided proper dccumaxation to tVorld Oil Environmcn[al Services to rebut the presumpt;cn that this waste was mixed :rich other hazardou vaste.l agree to accept the additional charges for the disposal of this
<br />' � yv tste tf the infermatiori h rve provided about this•rraste iz Incorrect "
<br />Q,3}Thi�s waste 1s tram a.tankwhichCollects waste oil rrom Household "dgit-yourself(DlYJ and/or conditionahy.ezempt small quantity generator�€CESQG) sources, to .hebest of my knd.vlydge, the onlywaste oil contained
<br />in my pIYICHSQG coliccUen tank is:3oteylrom'DtY and/or CES4sG<_vurtes�i Lhavenotmixed this waste oil :vith'ariy ether hazardous tivaste or vraste oitfrom other sources�Cagree to°accept the additional charges. for dispo;Sl
<br />of this vette if `the information I have provided about this waste is incorect -
<br />( c�enerator�/ c€�stnmPrs MUST.read the following text and check the associated box)
<br />!'�a j�;1 yrh =i latyi•{ji3antity+3•g4ysJtur. t 4r iiy lHat I Imve u t7iu�(am.l t.Ia« «r r�.,a�e Ut •olirmr and tc:Icity of armta generated to the degree f Hnve deteni7ined to he ecpnrmically p,a..t _,.Slc and that I hoee
<br />Ti++ rrlj�rvldual si:gt i r{} in
<br />as tnc?aS�kJ. tisartgt3 and
<br />r
<br />Print Name
<br />�sei fa
<br />forego; nrdispos at aur��ntty available to me which ramunizes the present and future threacto human fife and the environment• Vr,if; am a small quandtyueocrator,l
<br />raste generatirn and :elect the be;tcvsste rnaragcment imz(hod that is awilahl? tomeihat I can affwc#, -
<br />oov nn behalf nFru.tomer reprs^rats and rarrants thot he/she has cite authority to bind Cusromer, that the forooing descriptions ofnraste and rmai�riah arc true and accurate
<br />transpvriatiun in .+ccorrlance s.ith appl.,able nate and fedrral4egufniicns,and that Customer shall abide and Le bound by the 5[andarri Tc rrns ancj,C.�rrdittnns on the reverse
<br />` Date jf 1
<br />Print D
<br />ame
<br />
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