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FOR SERVICE CALL: SERVICE ORDER AL SERVICES, DBA FORM NO. WOES004-B(8/78) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICE ORDER N0. FOR ACCOUNTING CALL: 562-231-1550 WORLD OIL S ENVIRONMENTAL SERVICES. h+ 7300 CHEVRON WAY, DIXON.CA 95620 p 1-800-727-2879 P W W W.WORLDOILCORP.COM TRANSPORTER EPA#CAD028277036 r P ER # PURCHASE ORDER# ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES IRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# PART# DESCRIPTION CITY UNIT PRICE QTY P/U TOTAL CASH RECD: CHECK # — TOTAL WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS STATE CODE 221 OTHER: 1 STATE CODE_ DESIGNATED TSDF: _ - - -- -- - - -- ---- — -. _ _ ALTERNATE TSDF: .---—_-- — -- ---- -- ----- - -- - DRUMS P/U: EMPTY DRUMS:—__ FACILITY:___ _ BSC -- - -------- - --- GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) 6y slgmng blow I hereby certity that 't (Waste oil generator/customer MUST check ONE of the following three boxes) U 11)1 have not mixed any of the where described.boas with Any other hazardous waste.the total held.content Is LESS than i3Ooo ppm,and the waste does not eonuen any PCBs.I have complied with the requirements of the applicable Caiimnd.used ell man...Mae,regulations Id determine this Is true.I agree to accept the additional Ie Incorrect chargee ler the disposal of this whsle If the Infameadde I have provided about this waste 0 121 have not mixed any at the waat.dasctlbad above with any other hazardous w,a a.One total herds content is GREATER than 1,(X0 ppm,And the waste does not contain any PCBs I have provided Proper documentation to World 011 Environmental Service.to rebut the presumption that thie waste was mixed with other hazardous waste.I agree to accept the Methods charges for the deposal of inle waste II the Information I have on,wase about this enet.ls Incorrect E 13)Thle weats 1.from a one which Called¢waste oil from household 'dell-yourself (OIY1 ana/or coneldodally exempt Small quantity generator(CESOG)source..To the best of my knowledge,the only waste oil cimuahaa In my OIY/CESOG collection tank is sotey from DIY and/or CESOG address.I have not mixed this waste an with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal of this waste 11 the Information 1 have provided about this waste Is Incorrect (All generators/customers MUST read the following text 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 practicable and that I have ael.eted the practicable method of treatment.storage.or disposal currently available 10 me which minimine the present And future threat to human life and the environment. This Individual sigNng In Ira space set tenth below on thMalf of customer represents and warrants that revere has the authority to bind customer,that the forgoing descriptions of waste and materials are true and accurate as packaged.marked,and labeler,are ready for transportation In accordance with applicable state and federal regulellons,and that customer shall¢evict¢ by the Standard Tema and Conditions on the reverse side of this Service Ord.r Service Orders with an associated hazardous waste manllael(either site specific or consolidated)are sub=to an EPA Fee. These lees cover the EPA peas-through fee and administration of the ek1en11¢at program. These lees vary based on Manifest type, Applicable fees will appear on your billing Invoice. .. Customer Signature Date Driver Signature Date Print Name Print Driver Name