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FOvR SER1/ICE CALL -SERVICE(OfDI'�t
<br /> DIXONOFIGE ASBURY ENUIRONMENT �.SR1tiCES, DBA FORM,'No WOESoo�s (ati
<br /> p r r x r :SERVICE ORDER NO 3 '
<br /> i'8a0 T27,2879
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<br /> FOR ACCOUNTING CALL
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<br /> DATE REIRE „f 'r QAfE ENTERED `. NEXT SERVICE DATE;;. C1gTONfER E,A fi# ' ILL of LADING/11tAN1FE5
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<br /> fi WNASTE t�ISP.OSAL INI'QRMATIC3N
<br /> NON-RC RAHAZARDOUS WASTE,LIQUID(USED OIUIVIIXED'OILS) ” STATE"OODE 221
<br /> NON-RCRA HAZARDOUS WASTE,,LIQUID(ETHYLENE GLYCOL SOLUTIONS) " STATE CODE '" r '
<br /> QTHERr,
<br /> DESIGNATEDTsbi -"
<br /> ALTERNATETSDF:
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<br /> DRUMS P%l1 ,'.EMPTY;DR11M5, f FACILITY � BSC
<br /> GENERATOR WASTE CERTIFICATION(PLEASE`CHECK THE APPROPRIATE BOX)
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<br /> Py signing below i hereby certify that:.:, '
<br /> i (Vlfaste"oil generatoilcstorner MUST check-ONE�of the folloW(ng'three boxes)
<br />' liiaVenot,mizetl'an'ofthe"wasted esakeaaboyewltb6ny'other`hkardouswaste;thetotal'lalidecon[esti`sLESSthoni000pptnahiltfiewastedoes'rdecdntaihanyPCBsahavecomplledwifhtherequlrements'of''
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<br /> he applicable California used oil management regulations to determine this is true.l agree to accept the additional charges for the disposal of thiSwaste if the information I have provided about this waste is incorrect'
<br /> tt S421 have notmixed any of the waste described above with any other hazardous waste,the total 6a(ide content is 6P ATER than 1,000 ppm,and.the waste does not co�grain any PC8s.1"
<br /> have io`ide4 ro rdocumentationtoWorldOilEnvirdnmentaiService;torebutth¢presurpptionthatthiswastewasmixedwithothgrhazardouswaste,lagreetoaccepttheadditionalchargesforthedlsposaIofthis
<br /> waste if[he infoimatiori l i ave provided about this walte is ince rrect
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<br /> "�p3"fhi Waseisfrom�a�ta kwhich'colledswasffi'oilfromhousehold"do=it-ourself"(DIY)andlorcondltlonaity:exemptsmailquanutygeneratoi(CESOG)sources:Tothe bestofmyknowledge the only waste oil.cont ained
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<br /> inmyDI' CESQG`collectlbritanklss*oleyfrom'DiYiandlorCESQG3ourcesiihavenot[nixedthswasteoil'with'anyotherhazardousiwaste`orwasteoilfrontothersources.Iagreetoacceptaheadditionalchargesfor disposal
<br /> oft his waste if the information I have ptgvrded about this waste is incorrect.
<br /> (Ali generators/customers MUST read the following text and.ch�ec e associated°box:) '
<br /> kif'l am a large quantity generator,'i certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1,h etermin d to be economically practicable and that I have
<br /> "sele'ctedthe practicablemethod oftr`eatmerii;storage,or disposal currently available tome whichtnininiizesthepresentandfutuiethriattohd n:lifeandthe nvuonment;Or,iflamasmall quantity generator,l
<br /> fjave`made a'good faith effortto minimize my waste generation and'selectthe best 06ste'management method that is available to me that l aff6i "
<br /> This individual signingin the space:set forth below on behalf of Customer represents and warrants that he/she has the authority to bind stomer,that th orgoing dew E f waste and materials are true and'accurate
<br /> as packaged,marked and labe ed,are ready for transportation in accordance with applicable state and federal regulations;and that Cus mer shall abi nd be bound by�t` tandardTerms and Conditions on the reverse
<br /> side of this Service Order.
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<br /> Customer Sign ure Date er I nature Date '
<br /> Print Name Print Drivers Name
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