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FOR SERVICE CALL: SERVICE ORDER FORM NO-WOES004-B (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 WORLD OIL <br /> �� <br /> ENVIRONMENTAL SERVICES,•• <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> I 1-800-727-2879 � - - <br /> P WWW.WORLDOILCORP.COM <br /> E <br /> D ,t TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <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 I CITY UNIT PRICE OTY P/U TOTAL <br /> _ TOTAL <br /> CASH REC'D: 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 /> DRUMS PN: EMPTY DRUMS:. FACILITY:___ BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By elgning below I hereby cerlify,that: <br /> �9 (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> a I I I hnvo not mixed any of Rhe wants ddseflbed obova with any ainar htxsrdou6 waato.the Intel halide Coal@nl is 4ESS than 1,000 ppm,and the wattle dont not conlaln any PCBs,I have <br /> "molted with the tagViforn on Is 0 the applied bis Call total us ad alt hamsgamenl logo is lions In delel Inrna Ihis la True.I agree to ecce pt the addilledal ch arse for the dlepoaal of this waste If <br /> iho Informatloh I have provided nboul Ihlq wndla In Incorracl <br /> 0 R21 have not mixed any of the waste described above with any other hazataoua%vomit,Ina total hniide content in GREATER than 1,000 ppm,and the waste dote not contain any Pces.I <br /> hove provided proper daoumontallon to World all Envfronmettlist Sorridae to robot the prosumptlon that Its Is waste wea mixed with other hsfardevs waale.I agree to accept the eddlflonai <br /> Cheroot ler the dis"snl of thin waats If the in forrnall nn I hove provided aboul No waste Is inaoflaal <br /> 0 13)mit%W11114114 from a wool@ all from houlebold"do-II-vuumalf"(OIY)andror conditionally exempt small gnanFlty yvhxerelar;CE$QG}todrett,70 the dart a1 my <br /> knowloddo,the aniy waste all canialnod In my 01-W CESQO aolleellark inn it ie aoloy f tom DJV AntWof 0ES00 naurcea.I have not mixed thin wattle all Witt,any ether haxerdoul west@ 0 weeie oil <br /> from*Ili Of sourcoe.1 elites Io accopl the eddl11011!!dhtrpds for disposal of I 1111 wavle If the Inform mllop I have provided about IN we ale Is Incattoct <br /> (ATI generators/customers MUST read the following text <br /> I certify IheI I have a Rrogrmrn In pled to rrduce Me voWm9 and toxicity of waste generated to the degree I have de term Ined to be soon amlcalry pros tic abit and Shat I!hove sataclad the <br /> practicable mot had of lroalmem,storage,or dlepoaof 0urtenlIV evadable to me which mInImlzan the present and future threat to human life and the onvirdnnhent. <br /> iI'll 9 Ind!vidudl sig nil lg In the gppcv lot refill Wtow on babait as ouatarhtdr ropro7onts and wa rrnnls ilk lWaha has lh@ auinnrliy to b1nd cuelarnes,that the Iorgollag doncil pllang of waste <br /> and malednld are Itlla and aCaureta as packdg hid,mwkdd,and Inuolnd,ora eondy Idr uennpottnllOn In acCORfaaGe with sppllcabla @teia and tldaial reyvletlone,and lhgl cuslvnxer ahAll A61tic <br /> Dy the Sfnndnrd Tsrmo add Condillona on the ravwea aids or Ulla sorvico Oxddr, <br /> Servlce 0rdere with an assocIsled hazardcue waste man!fee t(ell her site upecltic or consolidated)are subject to an EPA Fee.Thea@ fees cover the EPA paaa•fhrouph tee and edmi n rsl+el tan <br /> of the eManlfeat program. These fees vary boned on Manifest type.Applicable fees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />