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C) v= Q <br /> O Q <br /> C/) _ O N <br /> O X00 v <br /> FOA SERVICE CALL: -� N 0 <br /> O OtXnN nFrlrr .. SERVIC'F nRn�A 9($ f a) v oN m <br /> FOR SE - -- to NO-W0IIr >y N <br /> _ �IX O�ORFFI CE CALL- VICE ORD ER NO. N v <br /> e0 E SERVICE ORDER FORM NO.WOES() (7) 3 <br /> U) 27`2879 ASBURY ENVIRONMENTAL SERVICES, DBA SERVIC5ORDII h <br /> (rD <br /> 56 12ACCaUNTING CALL; <br /> r <br /> 155° O WORLD OIL <br /> a. <br /> H ENVIRONMENTAL SERVICES- gT-FI15S (D <br /> y Q Cf) <br /> P 7300 CHEVRON WAY,DIXON,CA 95620 f l <br /> F1 1-860-727-2679 <br /> E <br /> w W W.W ORLDOILCOR P.CO M <br /> T <br /> TRANSPORTER EPA#CAD028277036 CA <br /> 1� O <br /> 7f n <br /> CUSTOMER# 77 <br /> PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES O <br /> F CD O <br /> DATEREQUIREDO't <br /> DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING!MANIFEST# <br /> 1 S✓ <br /> aL � O <br /> PART# <br /> DBSCRIPTI0N QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH REC'❑: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-ACRA 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 /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> Sy signing below I hereby certify that, <br /> (Waste oil generator/customer MUST Check ONE of the following three boxes) <br /> 51)1 have not mixed any of the waste described above withany other hasardous waste,the total hallde content is LESS than 1,000 ppm,and the waste does not contain any PCBs.I have <br /> compiled with the re,c,ulhimherdii Of the appAcrible he ifa mation I have provided about this waste is Incorrect fornia sed oil management regulallans[o tletermine this is true.I agree to accept the additional charges for the disposal of this waste if <br /> LI 52 I have not mixed any of the waste described above with any other hasardous waste,the total halide content Is GREATER than i,000 ppm,and the waste does not contain an PCBs-I <br /> V <br /> have provided proper documentation this ass to t or d Environmental have rServiceseato rebs the presumption That This waste was mixed with other hazardous waste.I agree to accept the atltlitiona! <br /> Charges for the disposal of this waste IF the information I have provided about this waste is incorrect <br /> M7)T91s waste is From a tank which collect'waste oil from household"do-it (DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the hest of my <br /> knowledge,the only waste oil contained In m DIYI CESOG collection tank is salehfrom DIY andfor CESOG sources.I have not mlxed this waste oil wish any other hazardous waste or waste.,I <br /> from other sources.f agree to accept the additional charges for disposal of this waste If the Inlormation I have provided about this waste Is incorrect <br /> (Alt generators/customers MUST read the following text <br /> 1 cerilfy that+have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined to he economically practicable and that I have selaoted I <br /> p <br /> proof cable method of treatment,storage,or disposal currently available to me which minimizes the resent and future threat to human life and the environment. he <br /> CD <br /> This Individual signing in the space set forth below on behalf of customer represents and warrants that harshe has the authority to bind customer,that the forgoing descriptions of a (.Q O <br /> by°h Stanfals are true dard d Te ms and Conditl ns d accurate"packaged, <br /> n he revere side of thand is Ser ice Orderare y for transportation In accordance with applicable state and federal regulations,and that customer shwo"all abide v <br /> o EhaceManifeyi program.sociated These feeszardous waste manifest(e0e,-It-vary based on Manifest type.Appllcahlekc Or fees will appear e on your tilare llingct to an Invoice. Fee.These fees cover the EPA pass-through tee and <br /> atlmin}siretibrl <br /> Sy <br /> (D <br /> rn Date Driver Signature <br /> oDate <br /> Customer Signatureo <br /> rn <br /> Print Driver Name o <br /> Print Name 00 <br />