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O = <br /> v Q <br /> - -4 I2 <br /> FOR SERVICE CALL: SERV ORDER FORM NO.WOES004-13(all B) W '' (D <br /> N OIXON OFFICE — I j Cn <br /> 1 e0f]-727-2B7g ASBURY ENVIRONMENTAL SERVICES,DBA SERVICE ORDER NO. <br /> � 00v <br /> r O � N <br /> CD >C NO <br /> (D FOR ACCOUNTING CALL: OWORLD OIL Do oN m <br /> 562-231-1550 N <br /> F4 = <br /> MENVIRONMENTAL SERVICES- N v <br /> � <br /> a: <br /> (n k 7300 CHEVRON WAY,DIXON,CA 95620 QUEST RESOURCE MGT - FtRE n 3 <br /> 1 FIRESTONE#0287413 t-800-727-2876 AY CD <br /> P 720 E. HAMMER LANE= 3481 PLANA PARKWAY n c- <br /> W W W.W ORLOOI LC ORP.COM <br /> D TRANSPORTER EPA#CAD028277036 THE COLONY,TX 77W v <br /> T STOCKPON,CA 95210 M72)464-0004 ¢ <br /> 0 (209)951.2403 m <br /> HALIDES -I <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN 8Y M <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE <br /> CUSTOMER EPA# BILL of LADING/MANIFEST# U) <br /> b O <br /> QTY UNIT PRICE OTY P/U TOTAL p <br /> PART# DESCRIPTION P <br /> 55-OfT 65 GALL 9N OfT DRUM fRECONDII�CIfJE(3] <br /> ~ FAT r+ TOTAL <br /> CASH REC'D:_ _ CHECK# <br /> WASTE DISPOSAL INFORMATION STATE CODE 221 <br /> F+ NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS) STATE CODE <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: account Managet Sar+Rea <br /> DRUMS PIU:_ _ EMPTY DRUMS: FACILITY: BSC_ <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby Certify that. <br /> (Waste oil generator/customer MUST check ONE of the following three boxes <br /> ..I#1J I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 ppm,and the waste does not contain any PCBs./have <br /> complied with the requirements of the applicable California used oil management regulations to determine this is true.I agree to accept the addilinnal charges for the disposal of this waste i1 <br /> the information I have provided about this waste Is incorrect <br /> er dous waste,the total holide <br /> tent <br /> ATER than <br /> ppm.and the <br /> te does <br /> contain any PcBs-I <br /> 0#21 have riot mixed any of the <br /> provided proper documentatiowaste World Old/Environmental withny othServices for abut the presumphon that thisnwaste was Eml ed with other hazardous Wastegl agree to not <br /> accept the additional. <br /> charges for the dlsposal of this waste if the information I have provided about this waste is incorrect <br /> ❑e3J This waste is from a tank which collects waste oil from household"do-ii-yoursel(DIY)and/or conditionally exempt small quantity generator with any Sources.To the best of my <br /> knowledge,the only waste oil contained in my❑IYf CESOG collection tank is soley from D1Y andlor CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste <br /> horn other sources.I agree to accept the additional charges for disposal of this waste it the Information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text <br /> I cedity that 1 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 selected the <br /> practicable method or treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. <br /> and materials are grin and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that customer shall ab <br /> This Individual me signing re rtte space set forth below an urrebehof customer represents and warrants that helshe has the authority to bind customer,that the forgoing descriptions o waste <br /> by file Standard Terms and Conditions on the reverse side of this Service order. <br /> A Fee.These lees cover the EI Apass-through Ise and administa, <br /> ciatfsvto manifest <br /> festJr sits <br /> pcificor ed)are <br /> sujettoan <br /> service �� with arl awill appear billing invoice. <br /> (D <br /> oI Nee�� est program. These based a O <br /> +- O <br /> Date <br /> Driver Signature Date � n <br /> Customer Signature o <br /> (D <br /> cn Print Driver Name CD <br /> C) print N , <br /> PTO r' CD <br /> 00 <br />