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FOR S`ERVIGE=CALI_: SERVICE ORDER <br /> DIXON OFFICE AS#3URY ENVIRONMENTAL SERVICES, 013A FORM NO.WOES004-B <br /> 1-800-7-A5BURY SERVICE ORDER NO. <br /> gra <br /> PARLIERs-. <br /> 559-498-0240 <br /> CHICO <br /> 800-733-9043 WORLD O I L <br /> 5 <br /> ENVIRONMENTAL_ SERVICES- <br /> H 1300 SOUTH SANTA FE,COMPTON CA 90221 <br /> I <br /> ' LOS ANGELES OFFICE <br /> p <br /> 1-800-974-4495 <br /> 0 <br /> r TRANSPORTER EPA#CAD028277036 <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDERTAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 7 ?- . <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> CASH RECD: CHECK# TOTAL <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATET5DF: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECKTHE APPROPRIATE SOX) <br /> By signing below i hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> =A1)I have not mixed any of the waste described above with any other haza rdous waste,the total halide-content is LESS than 1,000 ppm,and the waste does not contain any PCBs.I have complied with the requirements of <br /> the applicable Cafifofnia used oil management regulations to determine this is true,I agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is incorrect <br /> =112 1 have not mixed any ofthe waste described above with any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to world oif Environmental Services to rebut the presumption that thiswaste was mixed with ether hazardous waste.I agree to accept the additional charges for the disposal of this <br /> waste if the information I have provided about this waste is incorrect <br /> =93)This waste is from a tank which collects waste o1i from household"do-it-yourself"l[hY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my knowledge,the only waste oil contained <br /> in my DIY!CESQG collection tank is sc,4y from DiY andlor CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal <br /> of this waste 7f the information I have provided about this waste is incorrect <br /> r-���� (AIL generators/customers MUST read the following text and check the associated box.) <br /> LJ94)If I 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 I have determined to be economically practicable and that I have <br /> selected the practicable method oftreatment,storage,or disposal currently available to me which minimizes the present and future threat TO human life and the environment;Or,if i am a small quantity generator,I <br /> have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me that I can afford. <br /> This individgal signing in the space set forth beiow on behalf of Customer represents and'warrants that he/she has the authority to bind Customer,that the forgoing descriptions of waste and 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 be bound by the Standard Terms and Conditions on the reverse <br /> side otthis Service Order. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />