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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL:231-1 <br /> 5wonLo OIL <br /> ENVIRONMENTAL SERVICES., <br /> 5 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H 1-800-727-2879 <br /> P WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CA0028277036 <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 QTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIUMIXED 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 PIU: 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 /> Q #1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is LESS than 1,09 ppm,and the waste does not contain any PCBs.I have <br /> compiled 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 waste If <br /> the Information I have provided about this waste Is incorrect <br /> 0 #2 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 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 I have provided about this waste Is Incorrect <br /> Q #3)This waste Is from a tank which collects waste all from household"do-it-yourself"(DIY)and/or condltlonally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIY/CESQG collection tank Is soley from DIY and/or CESQG sources.I have not mixed this waste all 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 /> (AlI generators/customers MUST read the following text <br /> I certify that f have a program in place to reduce the volume and toxicity or 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 available 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 heJshe has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurate as packaged.marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations.and that customer shall abide <br /> by fhe Standard Terms and Conditions on the reverse side of this Service Order. <br /> Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> ......eManlfest program. These fees vary based on Manifest type. Applicable tees will appear on your billing Invoice. <br /> / r <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />