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FOR SERVICE CALL : SERVICE ORDER ,
<br /> DIXON OFFICE �� � E � `/IR iVMEN`GAI . SERVICES , FORM NO. WOES004-B (8/18)
<br /> t-m800-727-2879
<br /> SERVICE ORDER NO,
<br /> FOR ACCOUNTING CALL :
<br /> 562-231 - 1550 WORLD
<br /> OIL
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<br /> ENVIRONMENTAL SERVICESTh,
<br /> H 73001 CHEVRON WAY, DIXON , CA 95620
<br /> p I 3 h • r, r^ 4 ` t 1 800 727`m2879
<br /> D i >,f,j f '! :%3 �F... , I+' WWW. WORLDOILCORP.COM
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<br /> TRANSPORTER EPA # CAD028277036 ltOi"II ' A ° '
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<br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN I3Y HALIDES
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<br /> ©AiE REQUIRED DAavo
<br /> TE ENTERED NEXT SERI/ICE DATE CUSTOMER EP4 #
<br /> BILL of LADING/ MANIFEST #
<br /> f�tPART # DESCRIPTION
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<br /> IVON-FiCRA' HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS)"' y
<br /> NON-RCRA HAZARDOSTATE CODE 229
<br /> OTHER US WASTE, ` LIQUID (ETHYLENE GLYCOL SOLUTIONS)
<br /> STATE CODE
<br /> DESIGNATED TSDF:
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<br /> DRUMS P/U EMPTY DRUMS : FACILITY:
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<br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE I3oX)
<br /> By signing below I hereby certify that:
<br /> (Waste oil generator/cu.stoner MUST check ONE of the following three boxes)
<br /> Q . #1 ) 1 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, 1 have
<br /> complied with the requirements the applicable California used oil management regul
<br /> the Information i have provided about this waste is Incorrect ations to determine this is true. I agree to accept the additional charges for the disposal of this waste if
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<br /> Q #21 have not mixed any of the 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 011 Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste" i agree to accept the additional
<br /> charges for the disposal of this waste If the Information 1 have provided about this waste Is Incorrect
<br /> Q #3) This waste Is from a tank which collects waste oil from household "dolt•yourself' (DIY) and/or conditionally exempt small quantity generator (CESOG) sources. To A69 best of my L
<br /> knowledge, the only waste oil contained 1n myD1Y/ CESOG collection tank Is Soley from DIY and/or CESOG 'sources, i have not mixed this waste oil witi, any other hazardous waste or,aste oil .
<br /> from other sources, i agree to accept the additional charges for disposal of this waste If the information I have provided about this waste Is Incorrect
<br /> (All generators/ CUstorners MUST read the following text
<br /> I certify that I have a program In place to reduce the volume and toxicityI IP
<br /> of waste generated to .the degree i have determined to be economically practicable andthat t have selected the
<br /> Practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human life and the environment.
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<br /> This Individual signing in the space set forth below on be of customer represents and warrants that he/she has the authorityy to bind customer, that the for oing descriptions of waste
<br /> and materials are true and accurate as packaged, marlced, and labeled, are ready for transportation in accordance with appliand federal regulations, and that customer shall abide
<br /> by the Standard Terms and Conditions on the reverse side of this Service Order. g
<br /> cable state
<br /> Service Orders with an associated hazardous waste manifest (either site specific or consolidated) are subject to an EPA Fee. These leas talar t e EP p ss•through fee and administration
<br /> Of tlteeManifest program, These fees vary based on Manifest type. Applicable fees will appear on your billing Invoice.
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<br /> fiCuIIgmer Signature fiale �Driver ig u
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<br /> Print i1{anA — ,
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