Laserfiche WebLink
DIXON OFFICE—— <br />1-800-727-2879 <br />ACCOUNTING CALL <br />SZ 1550 <br />CUSTOMER # <br />DATE REQUIRED <br />PART # <br />ASB SERVICE SERVICE ORDER <br />ENVIRONMENTAL SERVICES, DBA <br />PURLgS R # <br />DATE ENTERED <br />L WORLD OIL <br />ENVIRONMENTAL SERVICES,,. <br />7300 CHEVRON WAY, DIXON, CA 95620 <br />1-800-727-2879 <br />WWW. WORLDOILCORP.COM <br />TRANSPORTER EPA If CAD028277036 <br />ROUTE # TRUCK # <br />c;/ <br />NEXT SERVIrF nnro <br />DESCRIPTION <br />FICIER.i <br />GIL. PILTk-R DRUM kl<-PL"ArCFh F_NT NO CHF -RC,'. <br />FORM NO. WOES004-B (8/18) <br />SERVICE ORDER NO. <br />CONTACT NAME I ORDER TAKEN BY <br />17I—NV. <br />HALIDES <br />CUSTOMER EPA # I BILL of LADING/ MANIFEST # <br />OTY I UNIT PRICE IQTY P/U <br />TOTAL <br />AL <br />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 <br />ODEOTHER:----DESIGNATED TSDF: 'r FS MPI "MENr, INC. P)MG US HI1'alitlUAY 95, -1 UIJA, A7_ W-455, cK8a_3 4.957,0 _ <br />ALTERNATE TSDF: <br />i3L t OTP *VV,' 'L3C SEW C Ar taunt Manager Sam Roa t <br />DRUMS P/U: ' f EMPTY DRUMS:_ FACILITY:__ - BSC <br />1, <br />y <br />v <br />v <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) I 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 />complied 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 it <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, ppm, and the waste does not contain any PCBs. 1 <br />rid Oil Environmental Services to rebut the presumption that this waste <br />have provided proper docuntelttation to Wowas mixed with other hazardous waste. I agree to accept the additional <br />charges for the disposal of this waste if the In <br />I have provided about this waste is incorrect <br />Q #3) This waste is from a tank which collects waste oil Irotn household "do-it-yourself" DIY lf' (DIY) and/or conditionally exempt small quantity generator (CESOG) sources. To the best of my <br />knowledge, the to only waste oil Contained In <br />collects <br />DIY:' CESOG collection tank is Soley from and/or CESOG sources. 1 have not mixed this waste oil 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 />(All generators/ customers MUST read the following text <br />I certify that I have a program in place to rod disposaltelurrentln availablelo me whlchf waste enineml es the present ando the degree I have futurethreat to human d to be economically <br />nd the envirronmenicable and that 1 have selected the <br />practicable method of treatment, storage, <br />Y <br />This individual signing in the space and labeled, are ready for transportation In accordance with applicable stale and federal regulations, and that customer shall abide <br />ace set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer, that the forgoing descriptions o was <br />At'l-ce <br />Materials are true and accurate as packaged, marked,Standard Terms and Conditions on the reverse side of this Service Order.ecific or consolidated) are subject to an EPA Fee. These fees cover the EPA pass-through tee and administration <br />Applicable specif fees will appear on your billing invoice. Orders with an associated hazardous waste manifest (either site specific - <br />ram. These fees vary based on Manifest type. <br />Y <br />Of the eManifest prog _— <br />-_) - dry. <br />Customer Signature <br />Driver Signature Date <br />Date <br />Print Driver ame <br />711 CM Receipt Filters N3082435 <br />