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FOR SERVICE CAL1 : SERVICE ORDER <br /> PARLIER ASBURY ENVIRONMENTAL 6ERVICES , DBA FORM NO, WOES004- D (1 /17) <br /> 559498 -0240 WO 250 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: VV0DIY N23$0841 <br /> 562-2314550 AF 150 <br /> WORLD OIL <br /> ENVIRONMENTAL SERVICESrM <br /> sI REMIER CHRYSLER DODGE JEEP RAM kA7 EAST MANNING AVE, PARLIER CA 93648 <br /> 1 :3460 NAGLEE ROAD 1 -559-498-0240 3460 NAGLEE ROAD <br /> P <br /> p WWW.WORLDOILCORP.COM <br /> E <br /> ' TRACY, CA 95304 TRACY, CA 95304 <br /> o ( 209) 820- 1815 TRANSPORTER EPA # CAD028277036 (209) 820- 1815 1 <br /> CUSTOMER # PURCHASE ORDET# ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> PRE147 2029 <br /> 029JONATHAN avelazquez <br /> DATE REQUIRED DATE ENTEREDXT SERVICE DATE �i CUSTOMER EPA # BILL of LADING/MANIFEST # <br /> 4/27/2017 CAL000385003 6A 9' 6 03 JJ <br /> PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> MIXED MIXED FUELS PER DRUM ! $225. 00 ( $225. 00 <br /> 55-C/TM 55 GALLON C./T METAL DRUM (RECONDITIONED) $52. 00 r $56. 18 <br /> BATCH * <br /> Cros Std ' TOTAL <br /> CASH RECD: CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON -RCRA HAZARDOUS WASTE, LIQUID (USED OIUMIXED OILS) STATE CODE 221 <br /> NON -RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATEDTSDF: <br /> ALTERNATE TSDF: - - - - - - — - — ----- - --- - - — - - - <br /> Li <br /> DRUMS P/U : EMPTY DRUMS: FACILITY: ._ BSC <br /> GENERATOR WASTE CERTIFICATION ( PLEASE CHECKTHE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> ( Waste oil generator/customer MUST check ONE of the following three boxes) <br /> O01 ) 1 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 contain any PCBs. I have compiled 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 the disposal of this waste if the information I have provided about this waste is Incorrect <br /> O 021 have 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 not contain any PCBs I <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste. ) 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 /> E130 3 ) This waste is from a tank which collects waste oil from household 'do-it-yourself' (DIY) and/or conditionally exempt small quantity generator (CESQG) sources, To the best of my knowledge, the only waste oil contained <br /> in my DIY/ CESQG collection tank is soley from DIY and/or CESQG sources. I have not mixed this waste oil with any other hazardous waste or waste oil from other sources. ) agree to accept the additional charges for disposal <br /> of this waste if the information I have provided about this waste is Incorrect <br /> ( Ail generators/ customers MUST read the following text and check the associated box. ) <br /> /a) 11 I am s large quimity grner.dnr I ( (,MN that I have a pnxjmns m plxa to radur.e the soiumo- and )minty til waste (senomted to thgdegree I ll (level mined to bo economically practicable and that I have <br /> %0'%vterf tl-a pracduWY methal of r7rahuent. nora�ln_ ro dislw;al cmlcnily avallaple to mo whirl) minllnitet IIIc prmertt and (u1uro, Illtcat 10 human cif., ilod the envitonmenu Or, II I am a small quantity generator, l <br /> is,hh• mat* a good IaBh a flair to mmimits nry tunic qunrtrrdirill ,rail A elr l thr, hiLit wasti* manmwinant mrilswo that it avallahle to me that I t an allard , <br /> tn . <br /> K otdi•Wdu.n gnlr in the space set forth below on behalf of Customer represents and warrants that he/she has the authority to bind Customer, that the Inuloing descriptions ofwaste and materials are True and accurate <br /> e, µackugr�l, i6iiio iJ m1 l.Ibetr•d are ready for transportation In accordance with applicable state and federal regulations, and that Customer shall abide an 01. 1 by the Standard Terms and Condltlons on the reverse <br /> dnnllhrt . IviteIII[ t9 <br /> t1d A7 <br /> r Sig attire l ate Driver <br /> Dat <br /> n <br /> Print Name <br /> Print Drivers Name <br />