Laserfiche WebLink
FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, D13A FORM NO.WOE'S004-B <br /> 7-800-7-ASSURY SERVICE ORDER NO, <br /> PARLILd <br /> 559-498-0240 <br /> CHICO AP- <br /> 8001-733-9043 WORLD OIL <br /> ENVIRONMENTAL_ SERVICES- <br /> 5 <br /> H f._• -r + 1300 SOUTH SANTA FE,COMPTON CA 90221 <br /> LOS ANGELES OFFICE <br /> E 1-800-974-4495 . .• . <br /> b <br /> T TRANSPORTER EPA#CAD028277035 <br /> p ,Jt - k.,, <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> i, <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE~ CUSTOMER EPA# BILL Of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> � � ? <br /> 1SE0 Off_ ERVI[CE' t„s� ii <br /> i <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMiXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATETSDF: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION.(PLEASE CHECKTHE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 11� 7}I have not mixed any of the wii5te described above with arty other hazardous 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 California used oil management regulations to determine this istrue.I agree to accept the additional charges for the disposal of this waste if the information I have prcyided about this waste is incorrect <br /> =i:2 i have not mixed any of the waste described above with any other hazardous waste,the rota€halide content is GREATER than 7,000 ppm,and the waste does not contaih any PCBs.I <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to acceptthe additional charges for the disposal of this <br /> waste if the information I have provided about this waste is incorrect <br /> =43)This waste is from a tank which collects waste 01i from household^da!t-yourself"tDIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my knowledge,the ontywaste oil contained <br /> in my DIY/CESQG collection tank is soley from DIY and/or CESQG sources.I have not mixed this waste 61 with any other hazardous waste or waste ail from other sources.I agree to accept the additional chargesfor disposal <br /> of this waste if the information I have provided about this waste is incorrect <br /> (All generators/Customers MUST read the following text and check the associated box.) <br /> IN 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 /> e acted the practicable method of treatment,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 seiec,the best waste management method that is available to me that I can afford. <br /> This individual sigTing In the space set forth belova an beha€fof Customer represents and warrants that he/5he has the authority to bind customer,that the forgoing descriptions of waste and materials are true and accurate <br /> as packaged,mar d 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 of this Servic4Order. , <br /> Custom$r Signature Date9 prsver"S'r'ggatu�e j, 1 Date <br /> Print Name Print.Q,rive'rs'Name <br />