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FOR SERVICE CALL: SERVICE ORDER <br /> PARLIER ASBURY ENVIRONMENTAL SERVICES, DBA FORM NO.WOES004-0 (1!17) <br /> 559-498-0240 'No 1 cry;,; SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WC7L)I't'0 / <br /> 562-231-1550 <br /> AF 110 to <br /> WORLD OIL <br /> ENVIRONMENTAL SERVICES. <br /> H 1IFf�Y LUBF#14778 14287 EAST MANNING AVE,PARLIER CA 93648 BROADBASIE INC <br /> P IW E HAMMER L..N. 1-559-498-0240 1471 SHORE ST <br /> E MON I 'HL.Y BILLING Wn?&OF WWWWORLDOILCORP.COM <br /> STOC K7OKCA 95210 TRANSPORTER EPA#CAD028277036 VEST SACRAMENTO, CA A5691 <br /> o (20@) : 52497190 (918) 375-1155 <br /> CUSTOMER r PURCHASE ORDER# ROUTE TRUCK CONTACT NAME ORDER TAKEN BY HALIDES <br /> t 2•i3t3 _ S{'HEC.�IJLE:O-1 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING./MANIFEST 4 <br /> PART DESCRIPTION QTY UNIT PRICE QTY P./U TOTAL <br /> i= tJ�sl L:MZ`I AL UiL AND GASUL44L FiLTERS <br /> Fl3R OIL FILTER DRUM REPLACEMENT- NO CHARGE <br /> ALL URN: PAAKE SURE TO LOCK SIDE HATCH fA 4FN DCY4F RATt�H <br /> Gw -itreet-s: OW *10 DK DIXON -DK100152 FXYIREi_1 TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: NCA-RCRA HX!AR[Y,-XJS WASTE. SOLID(FIL7FRS C0141.AINING CdL)STATF--001N-* 723 <br /> DESIGNATEDTSDF: <br /> ALTERNATE TSDF: 1 <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: - <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Osrl)I have not mixed any ofthe 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 complied 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 /> =#21 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.I agree to accept the additional charges for the disposal ofthls <br /> waste lithe Information I have provided about this waste is incorrect <br /> MN3)This waste is from a tank which collects waste dl 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 collecdon tank is coley from DIY and/or CESQG sources.l have not mixed this waste oil with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal <br /> of this waste If the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> "INK Ifl am a large quantity generator,i certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have <br /> selected the practicable method oftreatment,storage,or disposal currently available to mewhich minimizes the present and future threat to human life and the environment;Or,if I am a small quantity generator,l <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 he/she has the authority to bind Customer,that the forgoing descriptions of waste and materials are true and accurate <br /> as packaged,marked and labeled,areready for transportation in accordance with applicable state and federal regulations,and that Customer shall abide and be bound by the Standard Terms and Conditions on the reverse <br /> side of this Service 00- <br /> ustomer.Si n tUrL-""'—r'� Date Driver Signature ; �— Date <br /> Print Name Print Drivers Name T <br />