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w z D <br /> r-, 1 i .� -r- .- - f •y -r. 0 O QJ Q <br /> -' 9Y— em ODN C) <br /> �I <br /> _ N N <br /> — Y CD O O <br /> (D _ N m <br /> _ �(g16) N = <br /> ^S <br /> = FOR SERVICE CALL: SERVICE ORDER FORM NO.WpEp�NO' n 3 <br /> (n DIXON OFFICE 3 <br /> 7-800.727-2879 <br /> ASBURY ENVIRONMENTAL SERVICES, DBA sFRVICE O <br /> tt C7 � <br /> (D <br /> FOR <br /> r <br /> FOR ACCOUNTING CALL: Q Iv <br /> 562-2,31-1550 C).OIL CD <br /> CDs <br /> ENVIRONMENTAL SERVICES., T'Elie J U) <br /> " FIRE-SiTONE#028746 7300 CHEVRON WAY,DIXON,CA 95620 QUEST RESOURCE AY M <br /> 1-Roo-727-2879 3481 PLANO FARM m <br /> P 720 E, HAMMER LANE <br /> e W WW,WORLDOILCORP.COM <br /> T <br /> STOCKTON CA 95210 TRANSPORTER EPA#CAD028277036 f HE COLONY,TX i;056 U) <br /> (2179)957-2403 871n <br /> '1 484-0004 O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN 13 <br /> HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADINCa!MANIFEST# <br /> O <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> VVASlf=A <br /> 16.0/1 r 55 GALLON off DRUM(RECONDI tivNED) <br /> EATC tF <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OILlMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> i:rass S#Bests. Aomurx fila <br /> DRUMS P/U: licz EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below 1 hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> compiled with the requirements eul em oany f is of he awaste described <br /> Californiaabove <br /> with <br /> used all management hazardous <br /> regulations too1-1 determine this lide istis LESStrue.I agree <br /> than t accept ODD <br /> ppm,and the waste does not contain any PCBs_I have <br /> Q PP 9 9 gree to accept the additional charges for the tlis <br /> the information 1 have provided about this waste is incorrect 9 posaE of this waste if <br /> 0 p2 1 have not mixed any of the waste described above with any diner hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have charges for the dlspo aed proper oo!hes walon to ste it the information tOil or-ronal Service.I.have provided about this[tne waste is incorrect tion that this waste was miNed with anter hazardous waste.I agree to accept the additional <br /> d3)This waste is from a tank which coliecls waste ail from househoid"do-It-yourself'i01y)andfor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste ail contained in my Olyf CESuG collection tank is soley from DIY andlor CESQG sources. <br /> .I hav <br /> a e notmk axed t ei is waste <br /> oil with any other hazardrectous waste or waste ad <br /> Irom other sources.I agree to accept the addiifonal charges for disposal of this waste if the information I have <br /> (All generators/customers MUST read the following text <br /> I certify that I have a program In place to reducethevolume and toxicity of waste generated to the degree I have determined to be economically practicable and that t have selected the O <br /> practicable method of treatment,storage,or disposal currently available to me which minimizes the resent and future threat to human lila and the environment, (D <br /> This Individual signing in the space set forth below on behalf of customer represents and pwarrants that hefshe has the auplphorily to bind customer,that the forgoln (0 0 <br /> by�he Standard Termmalsorlais am trueeand nd acorals as CondRlons un the reverse cede aftlhis 5ervlce Ordeed.are r transportation in accordance with applicable slate and federal regulations,and bel customer at rsaste O <br /> Service Ciders with an associated hazardous waste manifest(either site specific or consoildaled)are subject to an EPA Fee,These tees cover 1ha EP tomer shat{abide <br /> of the eM nffasl program. These fees vary based an Manifest Type.Applicable fees will appear on your billing Invoice. A pass-thrnu ' <br /> � 9h fee and admin <br /> CD <br /> 0 :uston er Signature Date Driver Signature o <br /> � <br /> O <br /> 'rint Name Print Driver Name 00 <br />