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A-600- ?27-2879
<br />r { E ..: ` N
<br />CUSTOMER
<br />S ii - .0 PURCHASE�.......�:....�.....,.�.._..�..ORDER 4 ROUTE: 4 ' MUCK ,t 'CONTACT tA€;E O N)- i tMi s Y 1 S
<br />L
<br />r € CY( €
<br />CASH RECD,- CHECK 4
<br />LL NON-, CRA HAZARDOUS WASTE. LIQUID (USED 0iivPIXL--D tLS) STATE (;;ODF, 221
<br />NON-RCq RA
<br />OTHER:
<br />HAZARDOUSWASTE, Li ll0 (ETHYLENE GLYCOL C' LU T?€�I S-1 S t� E-- K` 0U. E.]
<br />HALTERNATE TSDF�
<br />GENERATOR WASTE CERTIFICATION (PLEASE CHECK TW APPROPrH t F r 0)0
<br />F?y sEgnincg celew i heroby certify that'
<br />(Waste oil generator/custainer MUST check ONE of ffi f0xowing thre4 bo xe,
<br />11-1 "'0 1 have nor mixed any of the vuasfe described above with ariy othez' hBZerd0Li',, w?Ete the totaa W -de is U. ss ihn�l 1300",, PPM trr"d the vtapsta aet,s !)ot coi,t i� an [haw"
<br />coopiied wi8h the requieements of Oie applicable CaGfeeaia used Gil rnanagetneht, n.gctlaflc ",a deie! amine, , ,is -s true, i a.� e_ .o .:cc_ -p t �r.
<br />the intorrraai`ron 1 have peolitmn 117aut thls waSIL ;s incorrect
<br />'.� "?.: f have not mixed ars., of the waste dssCribed lbove with any other hazardous :,'aste, trie joraq i,aii ce _oa:?ant is GREATER !h^r. r. -_ .',UO ppni, :,� . th_l. -,=�s ,.e C: , � , a.�• . :v._.._ ,
<br />have provided proper documentation to World Gil Environmental Services to rehu` the pres,wrp`.ir:in ,,.?i tia�� n-x_oe..+. ;.; o,d _
<br />charges for fhe disposal of this waste if the 'jiformauon i have crcvidecl iUcul tbis wane Is €ncctrred
<br />-1 a3} This :waste is from a tank which :o€lects. wraste rli Irom hacrsehoid "do�if-voufseW; MM iCESSC G,. .: r, the b -n? o
<br />4 ,Ic,Medge. ?tie oniy waste eii Ccntained in my My CESQG C,08ection tank is Soley From NY and.ar C: F £,FG s-.r�afer�s-' haw -e :nE :rued r�;s e, c a.€lith z : c -tet
<br />from: other scarcer, i agreetc aCCQPt Idle asddltional charges for disposal of lhls waste j, tit. it ro,w8tie" { haave p,ovido 5 aUaaf tF s is ir.�orro-3r.:
<br />(All generaf rst customers MUST read the toflovVing text
<br />I corllfy that 1 have a progsaw in plaeet io recuee the vo€ume and toxicity of vaaute q.,nemted fa the degree 1 dciLn:jmcd tc be:
<br />,'r.,
<br />prat7iCl lle method of #:; estmen£, SCorag?� pr disposal currently avai€alsEe. ter mt , - €rich n7iir ¢ alzas aha peesca± rani fr:4arc the -ai 17. human ".c ar;et r e <�r, vi rc. ci= -jai.
<br />i I,is individual in the q 2ce set fn{'til helow orl pe3?alt of nustflmer rnpreccil1 s 1Cd wamints Chat he'sNo utas inGam. a£i'f:?f)L'7y to bi _.- stn Cl- l: "ff tI' ; .gGln �] (i4 �Fi-'�Oa_� c
<br />act} materia 16 are :rise anti neCnraYe as parka G-ieri, rnzarkari, and labeled. Arco rn2tiy €Gr iCHrsSPc�r#ttiiorl IpE aerorda•�ce v!!€": :3:,,r!;c obit et��c _zr, .. ,sear r_r ty�P,:a i,- ter,., f.ie _�,>L�; e, br>L!
<br />by iEte SfanCard Terms and CondrtEans on F9ie reverse crude of this Service Order.
<br />Service € i-eets 4w ith an associated haznrdot;rr wa-e manifest ieifhe!, SiiB 8pG'Clfie' of are 2C- n PA FC -^ Fees --,Lci,,r ihi . LOA .L -a- n", -
<br />w he ePmanifest prograrn, These tees nary based on Manliest type. Applicable fens wit° appeal on yc;irr ti3 €=n -y
<br />t 6
<br />€ usto er Signatu,re Date Sigoarture Date
<br />Pk"f€lt?vame � ._-r4Sflt
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