|
pOR.SERVICE CALL SER /10E ORDER
<br /> ASBURY ENV! 0NIVIIGNtAL,'SBRVlCES, DBA
<br /> DIXON OFFfCE` FORM NO W(�l=Sg04 11(4/17) '
<br /> r , I „3 v s �'> f,f, , t, ,
<br /> 1,-800 7 74287
<br /> 9 , " . SEIiT% ODE$ o
<br /> FOR,ACCOUNTi d CALL z'
<br /> 562-231'1550' _ 3
<br /> Wt) OIC.
<br /> EN1l[RONM -NT
<br /> A' SERVY[CES
<br /> �, i r
<br /> s [ All !`
<br /> 5 '
<br /> r 0 CHEVRON WAYS DJXON CA 95620y { M _ a
<br /> JIV � ► 1 800 727 287hl9
<br /> ,�. 4`
<br /> P WWVf%WORLDOILCOAPGOty
<br /> 9 � l�O x� ? r TRA�V b'T R 1 PA#GA D 2> 7703 t A-, 3
<br /> ' T. � WSP B E 6
<br /> Q`
<br /> €t$K
<br /> GUSTO'ER# PURCHASE()BOER#,. ROUT # =RUCK,#, ,,COI TACT NAME `# ,ORDEIiTAi(EN BY,v �,.HALIDES,.
<br /> l
<br /> r'r
<br /> DATE°REQUIRED DATE ENTERED: NEXT SE,RUiE DATE: ' CUS sOtIERkEPA#
<br /> " ItLof I ADIiGIMANI,FEST ,.r. ry.
<br /> w,ar k' .,.�s-.trs^t
<br /> ,r
<br /> "'PARTS ` DSCRIPfl01�1 " ..€ u ! X21 T lid , TAL
<br /> 4
<br /> TO ;
<br /> �tr .a n,
<br /> g ?�
<br /> c
<br /> e,
<br /> {
<br /> )a a-+ - K.j20 A
<br /> f 3
<br /> / t
<br /> � #
<br /> r r
<br /> 446
<br /> CASH,,Ec CIEK
<br /> INF012MAT10N�
<br /> NON RCRA I iAZARDOUS WASTE,LIQUID.(USED flit/M1XED''O1L`S) STAT£CODE X21 =}
<br /> NON-RCRA HAZARDOUS WASTE,LiQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE _ 3 ,a
<br /> OTHER
<br /> D'E,SI77
<br /> NAEDISI3F
<br /> AUER U
<br /> DRUMSPLU _._ �. .. -EMPTY DRUMS s ._ -_-. �. ..FACILITY; BSG
<br /> m
<br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX)
<br /> .. --
<br /> r_
<br /> By signing below i hereby cehify that:
<br /> 'j
<br /> (Waste-oil€gene`r'ator%cu'storrier MUST check ONE of the;folloWing three boxes)'
<br /> s.
<br /> `h a 'dtt a hazy ous 'aste'the'total halide'confenE isLESs than 1,000 "'rn;and tie Waste doe`s not contain an'`PCRs.I have om'lied with there"uit`emen' of.
<br /> i
<br /> +4�,Ni)thave'notinizedan`y`of'thewaste8esctibedaboveW}t ny r� td w pP Y P q,,_.
<br /> tfie applicable California used oil management regulations to determ(n'this is true.i agree to accept the additional charges for She disposal of thls waste if the I format(on 1 have provided about"this Naste is incorrect `
<br /> pN2 I have not mixed any of the waste described above with any other hazardous waste,the total halide content i5 GREATER than i,tR10 ppm,and the waste does'not contain any PC�s.1
<br /> have provided proper documentation Lo Vlotld Oil EnvironmepIal services to rebut the presumption that this waste was mixed With other hazardous waste,I agree'to accept the additional charged for,the disposal o£thls
<br /> waste if the d6irrnatign)have pJoyided'about this waste is incorrect
<br /> s'"o'contained
<br /> CD#3 This waste isfrom�atankwhich'collectsWa`ste'9ilfromhotsehold do=)'tyourselF°{DlYjandlorcoriditionalttexertrptsinaliquantiiygeherator'(CESQG)sourcesTothebestofmykndwledge the'onlywa te. fl
<br /> inn)' E$QG collecRoti°tank is Soley from DlY and/orCESQOsources''I have"not mlxi this waste oil wfth ah other hazardou"s waste ocWaste of{from othel ources.l agree jo accept the additional chargQs`fd'rdisp"I
<br /> s Y
<br /> of this waste if the information 1 have provided about this waste is incorrect
<br /> (All generators/customers MUST read the following text'and check the associated box) "' „'
<br /> tlected
<br /> o)if1amalargequantity generator,I certify that I have a program in place to reduce the volume,and toxicity of waste generated to the degree I have determined to be economically practicable and that Ihavethe pra,,cticable method of treatment,storage)ordisoosal currently available to,me which minimijes the present nd futufe threat to human life and the envirooh)en4 Or if l am a small quantity generator l ='
<br /> have made a good faith effort to minimize my Waste generation and select the best waste management method that is A ilable,to me that t can afford
<br /> This individual signing in the space set forth below on behalf of Customer represents and Warrants that he/she has.the autAority to bind Customer,that the forgoing descriptions ofwesteand materials are true and accurate`
<br /> as packaged;marked and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that Customer shall abide and he bound by theStandardTerms and Conditions on the reverse
<br /> t.
<br /> side of this Service Order. -
<br /> Customer Sign re Date I r Signature -Date
<br /> Print Name ;Print Drivers Name 1
<br />
|