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FOR SERVICE
<br /> DIXON OFFICE CALLt - SERVICE ORDER FORM NO . WOES004-B (
<br /> IF Fi qt, AS URY ENVIRONMENTAL SERVICES , ® A 8/18)
<br /> 1 =8004 728,79 SERVICE ORDER NO.
<br /> FOR ACCOUNTING ' CALL : IF
<br /> 562-231 - 1550 " '' '
<br /> OIL
<br /> F§
<br /> WORLD
<br /> ENVIRONMENTAL SERVICES x,
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<br /> H 7300 CHEVRON WAY, DIXON , CA 95620
<br /> i1 -800-727-2879
<br /> P IY3ti r fw�Yl tax t 411 °i .. (JfA 13 �,� 10„P . -
<br /> P , W. WW.WORLDOILCORP. COM
<br /> E . .. , �tti�rA:
<br /> D TRANSPORTEREPA # CAD028277036 t { ' 4, A
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<br /> IF
<br /> CUSTOMER ' # PURCHASE ORDER # ROUTE # 'TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES
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<br /> DATE REQUIRED DATE ENTERED ' NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST #
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<br /> NON-C3CRA ' HAZAFi ®OUS WASTE ;LIQUID (USD;QIL/MI)CED OILS) STATE CODE 221
<br /> NON-RCRA HAZARDQ,US WASTE, LIQUID' (ETHYLENE' GLYCOL SOLUTIONS) STATE CODE
<br /> . OTHER :
<br /> DESIGNATED TSDF:
<br /> ALTERNATE 'TSDF:
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<br /> DRUM S1 „ EMPTY DRUMS : FACILITY: BSC
<br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE SOX)
<br /> By signing below I hereby certify that:
<br /> (Waste oil generator/customer MUSS' check ONE >of the following three boxes)
<br /> 0 #1 ) 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, 1 have
<br /> complied with the requirements of the applicable California used oil management regulations to determine this Is true. I agree to accept the additional charges for the disposal of this waste1f
<br /> the Information 'l have provided about this waste Is Incorrect
<br /> 0 #2 l 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 Oil 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 I have provided about this waste is Incorrect
<br /> 0 0) 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 the best of my.
<br /> knowledge, the only waste oil contained In my DIY/ CESOG collection tank Is soley from DIY and/or CESOG sources, l have not mixed this waste oil with any other hazardous waste or waste 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/ Customers MUST read the following text
<br /> 1 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 selected the .
<br /> practicable method of treatment, storage, or disposal currently avallabfe to me which minimizes the present and future threat,to human life and the environment.
<br /> This Individual signing In the space set forth below on behalf of customer, represents and warrants that he/she has the authority to bind customer, that the forgoing descriptions of waste
<br /> and materials are true and accurate as paci(aged, marked, and labeled, are ready for transportation in accordance with applicable state and federal regulations, and that customershallabide
<br /> by the Standard Terms and Conditions on the reverse side of this Service Order,
<br /> Service Orders with an associated hazardous waste manifest (either site specific or consolidated) are subject to an EPA Fee. These fees �01r rst �e�P s through fee and administration
<br /> of the eManifest program These fees vary based on Manifest type. Applicable fees will appear on your billing Invoice, f = = f�
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<br /> � u tomer Signature Date
<br /> , . Driver Sign tures' a Date
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