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FOR SERVICE CALL: SERVICE 0iiDFR FORM NO.WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-287$ SERVICE ORDER NO, <br /> FOR AccouN}ING CALL: WORLD �� <br /> 662-231-1550 <br /> F N V 1 R 0 N M L%4IA'; S-RVICES <br /> 'I rju)Cl IL=VIION WA`r. DiXON. O.A,9_1,620 <br /> i -8100-727-2 a-;� <br /> n <br /> WWW.WORL.DOILCORP.COM <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMEp# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME rOROFR TAKEN f3Y HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUST60-R EISA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION - QTY I UNIT PRICE QTY PIU TOTAL <br /> i <br /> 1 <br /> - TOTAL <br /> CASH REC*D:- CHECK -- <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED Oji-.S) S'T'ATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE. LIQUID(ETHYLENE GLYCOi.,SOLUTIONS) STATE CODE <br /> OTHER: _ — <br /> DESIGNATED TSDF: -- <br /> ALTERNATE TSDF: _- <br /> DRUMS P/U:_ EMPTY DRUMS; FACILITY: BSG <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> ey signing below'hereby certify that: <br /> (Waste ail generator/Custoi5,i 7AST check ONE of the following three boxes) <br /> F, 01)!hove not mixed any of the waste de5cfted sbuve with any uthe°r ho-irrir•tis r: I iho total halide cotrtent In'...ri SS than I pliant,and the waste doss not contain,any PCH&I have <br /> eompliod with the requirements of the applicable califurnin uew?ol!rnnn�; -it .ti;im-,mun,ih€c Is trI'n, to riccept the additional chatgen for the disposal of this waste if <br /> I <br /> he Information I have provided about this waste is incurred <br /> 11 r2 1 have not mixes;:my of thn woste descrlher ataave with any otic „ •, y i;fu tuttrl 11,11lrtf canteni Ia 2MrATOi than I.DOID ppm.and the waste does net contain any PCBs,! <br /> have provldrxi proper docnmantntion to WorIJ GII Envimnrncrr tel Service„t rnblil 17b i .:umptiur that tii3r v w to urrrx mixad rdier odi"r I7tr>:arduutr waste.I agree to itcrnpt the additional <br /> charges for the disposal of thin waste If the information I hove?xovided about.hh;w:;.i incormct <br /> 0 #2)This waste Is frun:a tank which ral[ects wnets oil from hnusnnold-do-It youraw ir'(t71Y)andfrn cin litiunally exempt email qutentlty flarierntor(Cr:3CG)sources.To tho beat of my <br /> knowladga,the w,iy west*on contained In my VIY,'G f,9Qn colwintlnn tank is soiey from DIY nntuor t:Er',Qr n lurceo,I Ixe:ve not r lixud this Wd5te vii tYiEh illy UIIlt3f haaafti0l.ls kSl9Sts?6f V7SIStGe 8II <br /> from Other aotltcas.!agmo to arcopt the additlanae aharMa for diepoeal of Ihls wa lta If the+lnforlr,u3ur:::iavo provided alruut this waste la Incorrsef <br /> (All generators/customers MI 12T rear, t'_-T,following text <br /> I certify that I have n program in pltlr.Q to reduce thu volunip amu toxicity ref kanste qen °•--+j.,trr_..rlr=i rl a <br /> Practicable mat!tcr,al tr arttnon..ntorxfe,or disposal currrmtiy o.vallahla s r i,e4 srhicl Ito he ee at7nliticatly pract�aitlo next that!have selrlctCci the <br /> � i� -�i is human lilt fled!ha snvlronmedi. <br /> This Individual signing in the space set firth below ar behalf i bow.customa Nie aE z rarity to hind crsetathur,that lite torpoing deacrlptlona of wast® <br /> and lnator!als are tales al?d accurate as packaga:tt,inarked,artd itllsakxl ar i <br /> by the Standard Tsars and Canditlans on Fhm novenae s;de o;tl:Ic uervlrr a .ra r rritf,e;,nllr,�bio state and federal reguletiahs.and that cuetamo-.r shall ahidb <br /> Service Orders with all assac€ated hazardous waste;nanitaat(ehhmi sito prcEfb, ^. ,-.e Nub��•ct to wii;Eta/;Pue. ThL=`sea saver tha E11A p�rfst-thmugh fee and rxlmtnledration <br /> of the etelantfesi prograrn, 9-base foes vary 4ased nn rTAn[fest Mm. Appl,enble tee_ i!° ...i -n y�e=r IN�ihn;t invnicn. <br /> j Customer — /— <br /> Signature A Data~ <br /> Drivel'Signature Date <br /> Print Name -- — — — - — — — — — — <br /> Prim`, Flrivor►+lamp <br />