|
r
<br /> ;' FORM N01OESQO �B (117)
<br /> ASBLIRY�Ni/IRflNMENTAL SERIlCES,[3BA' i
<br /> L'Wi 5x" "T = ^" ,-}c-" r" ,r J s i i t SSERVICE�RD
<br /> ].'3��- `„, �.a jj 't�-ssj afsu#s �3r 3 ^u„ s 2 9,i r s .�`sT.3'r," rqs - aes i r s3z —s3 t ER i
<br /> }Awdv, x? -WM4 1 L ,'}>r-s rr'X s s
<br /> 7R�• '�� ' kF13#Y??-�+,ti;:, ttj„�,- *#k. ,=7 'ru t,..t.nss•srr>.s#.3wili, a ,H;d ,'' '.ted}) it-r-7•fir 31,�.a'a+t tai} `a- z s
<br /> f9
<br /> 77
<br /> t, ,,.;.,,a `rv., ,. .. r�s���,xs•J.�.,,,-}i'•�vn#..�a,J; w.,-;i._`r'. .�., ,,. s ,y},�
<br /> .4d a!s ''� sl Flab a+ s its{
<br /> EV A �}�//� N A 9�j�j
<br /> $ J 1(,r ',x{3 5t:'.r^i l Y d..)S 'F }I n<sa a3 7309) Fdli �'-R 1Ti'1 1 C;A,t'J#.?'T�J/'t lih ! f .0 r? V AW"Ji
<br /> � � 1=$00 7 ASBRY
<br /> WWI�i IVORE©OILGORI�COM. z
<br /> r
<br /> t3 � rk A _ 4'-T#��kNSP(�1Rff}��PA#LA13Cf28
<br /> mT �#`dipp
<br /> 0 .O f I sts z4 ssz s, Ig d fare tr,i' 1. +7 � a
<br /> a t, �.; ...... d� zi n{<,�- 1 s ,3,: s +s ri 3..n,.•- ..et .-. ,�,v > ,. _ la•J.. t3..xE a„�. ..�+;- n .r...E -
<br /> {
<br /> Ct757OMER# PURCHASE ORDER#. Fi UTE# TRUC.K# CMACT NAME r. ORDERfiAKEN Bi' HALIDES
<br /> id 1l s, rz�tE 'n. �f S ke ie
<br /> DATE REQUIRED. DATE ENTERED NExT SER1lICE DRTE CC1ST{5n?IEiTPA'#' "" "' '°' =`RILE ofi i AD1NG71�lAN1FE57#
<br /> �rr5rn ra si rt t- ; Mi e s a” t t rrAp,Pis t °.azi'#sa”k t txsx k r r
<br /> }t,.>' }fl:.rNKs-i�X'+��"+ fz ,>: .-, ik.F;�ir r =sti vJxl a,elu a aJ ..asaag� l #r r t-taur�. ~xFr a.!- rr P '"`a
<br /> Tia m :i, UNIT}PRICE` QTYR/!1 :fOTA
<br /> PAR „. DESirRiPT_N
<br /> Ur, EA GALWA4 t
<br /> t .,: is c.}r ❑r Asa s 'a a itsstt,'c s s
<br /> - �? �•t
<br /> s
<br /> r .2z:1
<br /> 9
<br /> uo-
<br /> ? "
<br /> TOTAL
<br /> i
<br /> a
<br /> s
<br /> x
<br /> CM # — e
<br /> F11TI �a
<br /> rm } ✓ r� ci xaa } i lb 4 ,.,,.r,, - a +, a
<br /> NON,f2GRA 'WRDO ►S" ASTE,.LIQUID(USED OIL/MiXf{7 NATE COI�f l
<br /> t � QSTA
<br /> TECODE
<br /> NON RCRA HA Af DOI1S WASTE,LIQ (ETHYLENE GLYCOL SOLUTIONS)
<br /> > 77 77�77'7
<br /> SIGNATDTSOF = , _ `'
<br /> r: a,
<br /> tiAUERNATETSDF:
<br /> ^ +�ta'�.-�£- 4 r
<br /> DRll SEPIMI u
<br /> GENERATOR WAS1 CERTIl=1CA71b1 �1' EASE CFIECK_J F AP'ROPF(IAl E BQX) 'a
<br /> �
<br /> SysigningbeloWiherebycertify;hah
<br /> . .€v tx is .> -r )'P 71 1
<br /> r
<br /> a
<br /> .t a t Q� r� r star � s F► c E h foi wbd thr � Bks-
<br /> t e ti za ou "`ste;fie.totaihaiideeipntettT � SSthafi,,O p e ntthewAtdaesnotcomain9nyPC sB thaverompiledw7tljth requirements of
<br /> Itllihae'rfottnxedariyaftfaewaste'tlesfhbed'abgveivlthany_�h r a rd,;syra
<br /> ��- the apglicableeatlforniausedoilmaliagementiegufati ins to determine this istsuutagreetoaccepttheadd(tionalchargesforthedisppsaj'ofthiswa elfthe Information IhaveprovidedaboutthlswasieisIncorrect`"
<br /> I _ a
<br /> f e' ` bedabove' l;h art`otherhazardp4swa[e,the;totalWidecomeritls,q TERthan34oppt??.andthewastedoesnbtcontalnanyPCBs.I
<br /> 0
<br /> pi2lhavenptmizedanyofthewast descrl ,,.., .<„.: ,.„_�,..� ,n
<br /> ”" "'` E v'" n;alSerVlces;p,rebU;theprespnl�l hatthis+uastewasmixedwithotherhazardouswaste(agreetoaccepttheadditionalchargesforthedlsposalofthis '
<br /> have,prpvid d roperdocumentatiop'AA4rCd.QU n,_tronme <
<br /> viaste If Ife rtiatibn7 h�a4ppro3�detl abou This 0 00"W(
<br /> k fc rt3- rtr Y3 fr �+ ',.aa Ai,
<br /> 1,'i r,3-3 ua? -_, w.,<;d4°+ 'e,.�`a; 4 -, ,-.- "",jks sc `,�.#s,.,,a,.�ss`� -, ..r+ -1�
<br /> s s oA<mmh useffod oitYoySs(( 0-1y)add/9r P,,Spl � ivantih!9er;era;gfjC Stl�i)3Qtuc s7�h ;S4 y*�6�lq epniy�asi oJcontain r
<br /> ,.C�ag)3b v ���?IYfsbJ4hol est,W t�, 4., l $._..
<br /> y- yid"rnyY,yCES .,o1fE1,.P„.an.;".,.nks91eY,from;RlYnsUorE €(. 59ut�rsnlhavenotmiXed`thlswas”teolfY+i[FtapnihefbaZartlptisSStaste"prWa{s;eol!#togip3hRnapurSesild9reexp:accept;headdlUonalrhargesfordlsppsal ��...
<br /> ofthi`swa`stglftheinforinadghl iavepiovidedaboutthiswastelsincorrect " '
<br /> y :{A11 ger
<br /> eratop/customers MUSTr6�d th following text and check the associated ox}
<br /> }- `
<br /> } i to alar e u nti eneratpr`#'cetl ;haU aY, ;program.lnplacetp,reducethevolumeandtoxi4ltypfirafteg€nsrAp tothedegreglhaveeaterminedtobeeconomicaliypradicableand that lhave y
<br /> ..,,-. ._ in r df ure o a dU' R t, _ a @ 9 ty9ell
<br /> se! ; tl blemethpd ft5 4 m�9e Y51 pow'' ru�fgtitiY�v��a�?�S? 1?Y1il ,,�tnir p g 444 001-0vo, 4? .,.y ndtheenviro n 4irifi masm ll uanti eralor l
<br /> ecgd >!7r_Sa_. 9
<br /> fiaVt Pad4L9P4siraltheffor4t4>rtnim4+g y A e9an t�IiR[t?�Ld4",Igo h. _rna a9e41qR hod;ha ayDilabJ Sp Ale h?;L�an�ffQrctc rr _, d
<br /> ^rs' 3 .z"1ti °4si^f>i43J e'rxe`. J a'u',:=- ' ,t.>,,",J ;'ta >:• #„�m..„ ^3:; a;<w xl s, ,
<br /> if o»”f, '.a `}` �'" � `' ` ` "hehastheauthor .tdbindCustomer,thattheforgoingdescripttonsofwasteandmateilalsaretrueandac itpte
<br /> T}his,fhdivlduals(gninginthespacesetforShbelowonbehaltpffustomgrfepresentSandwarrantsthathels.� �. h, bidearidbeboundb the Standard Terms and Condit)pnsonthereverse
<br /> a;packaged,mar�sedandlabeled;are readyfortransportatiorilrlaccotdanewithppl[cahl¢st�teandfEde`ral"reguiattonsansitba;Cr7itomershalla Y
<br /> s
<br /> s1de of#hisService Order '
<br /> s.aa,.z-.� ,. r' s t �...,r �riz nr',.�}3'-ntrz xd. .. a
<br /> �l`t a*
<br /> Customer Signature Dafe Driver Signature` date^->
<br /> <�
<br /> " —
<br /> int Name--_
<br /> r. `- Print Drivarc,Nama_
<br /> . ,_Pr
<br />
|