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Jan 03 20 02 : 39p James 2099481693 p . 3 FOR SERVICE CALL: SERVICE ORDER PARLIER ASBURY ENVIRONMENTAL SERVICES, DBA FORM NO. WOES004 - D (1 /17) 559-498-0240 SERVICE ORDER NO. FOR ACCOUNTING CALL , 562-231 - 1550 WOnLD OIL ENVIRONMENTAL SERVICESTM 5 H 14287 EAST MANNING AVE, PARLIER CA 93648 T -559-498-0240 ; p p WWW.WORLDOILCORRCOM E T TRANSPORTER EPA n CAD028277036 O :';✓'r " CUSTOMER # PU RC HASE ORDER 41 ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA 9 BILL of LADING/MANIFEST # f PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL TOTAL CASH REC' D: CHECK # WASTE DISPOSAL INFORMATION NON- RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OIL5 ) STATE CODE 221 NON - RCRA HAZARDOUS WASTE, LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATEDTSDF: ALTERNATE TSDF: DRUMS P/U: EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECKTHE APPROPRIATE BOX) By signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes ) = 41 ) 1 have not mixed any of the waste described abovewith any other hazardous waste, the total halidecontentis _ES5 than 1 ,000 ppm, and the waste does not contain any PCBs. € havecomphed with the requirements of 11 the applicable California used oil manegement regulations to determine this is true. I agree to accept the additiona charges for the disposa' of this waste if the information I have provided about this waste is incorrect :::3 #2 1 have not mixed any of the waste described above with any other hazardous waste, the total halide content is GREATER than 1 ,000 opm, and the waste does not contain any PCBs. I have provided proper cocumenta.lon to World Oil Environmental services to rebut the presumption that this waste was mixed with other hazardoais waste. i agree to accept the additional charges for the disposal of this waste if the Information I have provided about this waste Is incorrect = 43) This waste is from a tank which collects waste ail from household "do-it-yourself" (DIY) and!or conditionally ex>_rnpt small quantity generator (CESQG) sources. To the best of my knowledge, the only waste oil contained in my DIY/ CESQG collection tank is soleyfrom DIY an dyor CESOG sowas. l have not mixed tbis waste of- with any other hazardous waste or waste oil from other sources. Iagree io accept tM add hional charges for disposal of this waste if the informat on I have provided aboutthis waste is incorrect (All generators/ customers MUST read the following text and check the associated box. ) ZD44) If I am a large qu an titygenerator, I certify that [ have a program in place to reduce the • olume and toxicity of wastegenerated to the degree I have determined to be economica' ly practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes thepresent and future threat to human life and :he envirorm = nt, Or, if I am a small quantity generator, ) have made a good faith effort to minimize my waste generation and select the best waste management method :hat is available tome that I can afford. This Individual signing In the space set forth below on behalf of Customer represents and vranants that he/she has the authority to bind Customer, that the forgoing descriptions of waste and materials aretrue and accurate as packaged, marked and labeled, are ready for transportation In accordance with applicable state and federal regulations, and that Customer shall aaide and be bound by the Standard Terms and Conditions on the reverse side of this Setvice Order, Customer Signature Date Driver Signature Date Print Name Print Drivers Name Received Time Jan , 1 2020 3 : 10PM No , ) 767