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Ail 1 <br /> i <br /> QMiER# I PURCHASE ORDER# ROUTE# TRUCK# (;ON aAG I NArMe <br /> !SAT-E ENTERED NEXT SERVICE DATE CUSTOMER EPA# <br /> i <br /> DESCRIPTION _ QTY UNIT PP?CE t OTY P/U� TOTAL <br /> _._PART#___ _ . . _ _._ _ ._.__ <br /> Cl <br /> { <br /> CASH RECD:---------__- CHECK.„. <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED O?LS1I STATE CODE 2e <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) NATE CODE <br /> OTHER:__.____ - <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> Li <br /> DRUMS P/U tml;l ry DRUMS: .-_ <br /> GENERATOR R WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOXY <br /> By signing beiow I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> . ”#7)I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 ppm,and the waste does not c - <br /> complied with the requirements of the applicable.California used oil management regulations to determine this is true.I agree to accept the additional charges for t. <br /> the information 1 have provided about this waste is incorrect <br /> C� #2 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 - <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree h.,...... .... <br /> charges for the disposal of this waste If the infont+ai!on I have provided about tills waste is incorrect <br /> F1 #3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt smart quantity generator(CESOG)sources.To:he b"sl ci+ray <br /> knowledge,file only waste oil contained in my DIY/CESQG collection tank Is soley from DIY and/or CESOG sources.!have not mixed this waste all with any other hazardous waste or wMe sit <br /> front other sources.i agree to accept the additional charges for disposal of this waste it file information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text <br /> I 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 Practical c'We that 1 11"'4e set::. <br /> practicabie method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human lite and the endo <br /> 'This individual signing in the spare set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer:that t <br /> and fnaterlalsere true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regu <br /> -»y the Standard Terms and Conditions oil the reverse side of this Service Order. � <br /> $8 <br /> rtdRe Orders with an associated hazardous warste manifest(either s��specific or consolidated)are sable t to an EPA Fee. These fees cover t!: <br /> of 2Ne 0%%rtt#est prdgrarn;.These fees vary based on R7unife:t _ e. Applicable fees willappear on your bili rr. rvcirc <br /> drti'iVeT ' <br />