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FOR SERVICE CALL : SERVICE ORDER FORVI NO . WOES004 - B (8/ 18 ) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA SERVICE ORDER NO . <br /> 1 -800-727- 2879 <br /> FOR ACCOUNTING CALL WORLD ® IL <br /> 562- 231 - 1550 <br /> ENVIRONMENTAL SERVICES , . <br /> S 7300 CHEVRON WAY, DIXON , CA 95620 <br /> H 1 . 800-727 -2879 <br /> P <br /> P WWW.WORLDOILCORP. COM <br /> D TRANSPORTER EPA # CAD028277036 <br /> T <br /> O <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # <br /> PART. # DESCRIPTION QTY UNIT PRICE OTY PIU TOTAL <br /> I <br /> _ TOTAL <br /> CASH RECD : CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON - RCRA HAZARDOUS WASTE , LIQUID ( USED OIL/MIXED OILS) STATE CODE 221 <br /> NON - RCRA HAZARDOUS WASTE , LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE _ <br /> _ OTHER : <br /> DESIGNATED TSDF : <br /> ALTERNATE TSDF : <br /> Li <br /> DRUMS P/U : 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 /> [� o1 ) I have not nixed any of the wastc dascrlbad abova with any other hazardous waste, the total Inutile content Is LESS than 1 ,000 ppm, and the wasto dons not contain any PCBs. I have <br /> contpllod with lho rectuliemenle of the appbr-abla Cmllmnla used oil management regulations to deleonhro this Is true. 1 agree to accept the additional charges for the disposal of this waste If <br /> the mformanon I have provided about Ible weatu In Inronect <br /> Q 02 1 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 conlaln any PCBs. I <br /> have provided proper daeumentallon to World OII Envlronmentnl Sorvicas to rebut the presumption that this waste was mixed with other hazardous waste. 1 agree to accept the additional <br /> chalgun for the dlspoeal of [his waste If the Information I have provided about this waste Is Incorrect <br /> 0 03) This wants is from a lank width eollucis waste oil Ilium household do lbyuurooll' (01Y) ondfm conditionally exempt small quantity gonorator (CESOG) sources . To the beat dl my <br /> knowtetge, lire only woslo oil coninlnod In my DIY/ CESOG collection tdnk ie soloy from DIV ands CLSOG sources. I have Vol Mixed this waste oil with any other hazardous waste or waste oil <br /> horn other sources I ograu to accept the additional chargoo for disposal of this vmele If the Information I have provided about this waste Is Incorrect <br /> (All generators/ customers MUST read the following text <br /> I 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 proclicable and that I have selected the <br /> practicable method of Iroatmant, storage, or disposal corrorrlty available to me which minimizen the present and future threat to human life and the environment. <br /> this individual algnhig In Iho apace Sol forth boiow on boholl of customer ropiusunts and worrmus that heJano has the authority to bind cuslomor, that the forgoing descriptions of waste <br /> and molorinla aro lino mrd accurate as pockagod, marked , not labeled, aro randy for transportation In accordance with applicable slate and federal regulations, and that customer shall abide <br /> by the Slnndoro Talmo and Conditions on the rovern0 olds of thin Service Order. <br /> Service Orders with an associated hazardous waste manlfest (either site speclllc or consolidated) are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> 01 the eManifest program. These fees very based on Manifest type. Applicable fees will appear on your billing invo .ce. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />