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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 5"^-231-1550 _ <br /> ENVIRONMENTAL SERVICES," <br /> s 7300 CHEVHCN WAY, DIXON. CA 95620 <br /> M <br /> I 1-800-727-2879 <br /> P <br /> P WWW.WORLDOILCORP.COM <br /> D 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 OTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> f ` 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 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 /> Q 41)r 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.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 th€s waste if <br /> the information I have provided about this waste Is incorrect <br /> 0 421 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 #3)This waste Is from a tank which collects waste oil from household"do-It-yourself"(DIY)and/or conditlona0y 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 WY and/or CESOG sources.I have not mixed this waste all with any other hazardous waste or waste ol1 <br /> from other sources.f agree to accept the additional charges for disposal of this waste)f 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 practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal curren[Vy 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 he/she 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 /> 1—the Standard Terms and Conditions on the reverse side of this Service Order. <br /> ice Orders whh 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 /> y�,.Ane eManifest program. These fees vary based 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 />