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FOR SERVICE CALL : _ SERVICE ORDER FORM NO. WOES004- 13 (8/18 ) <br /> DIXON OFFICE ASBURY' ENVIRONMENTAL SERVICES , DBA SERVICE ORDER No. <br /> 1 -800-727-2879 <br /> N3114681 <br /> FOR ACCOUNTING CALL : <br /> 562- 231 - 1550 <br /> 562- 231 - 1550 <br /> ENVIRONMENTAL SERVICESTM <br /> S 7300 CHEVRON WAY, DIXON , CA 95620 <br /> H GEVVEKE MOTORS - GEW003 1 -800-727-2879 <br /> P 102 HANSEN DRIVE WWW.WORLDOILCORRCOM 102 HANSEN DRIVE <br /> E TRANSPORTEREPA # CAD028277036 <br /> T LODI , CA 952640 LODI , CA 95240 <br /> 0 ('>_ 09) 368-0561 (209) 368-0661 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # . CONTACT NAME ORDER TAKEN BY HALIDES <br /> GEW003 CER-86 JAMES/EVELYN smartinez <br /> DATE REQUIRED DATE . ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILI of LADING/ MANIFEST # <br /> 12/24/2019 CAL000391238 (L %"JT r <br /> PART "# DESCRIPTION QTY UNIT . PRICE QTY ' P/U 77 TOTAL <br /> 55- C/TM 55 GALLON C/T METAL DRUM2 $ 84 . 00 . $ 181044 <br /> PAiNT PAINT RELATED WASTE PIR DRUM 2 a $0 . 00 <br /> EMS EMANiFEST EPA FEE & ADMIN - SITE SPECIFIC mANIFEc T 1 $ 25. 00 $ 25. 00 <br /> f M 2019 168 0551 °,{' BATCH A6 <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 /> LJ Cross Streets : Accaunt hn a <br /> ( DRUMS P/U : EMPTY DRUMS : FACILITY: SSC <br /> dd <br /> GENERATOR WASTE CERTIFICATION ( PLEASE CHECK THE APPROPRiIATE BOX) I <br /> By signing below. I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Q 111 ) 1 have not mixed any of the waste described above with any other hazardous waste, the:tolal halide content is LESSthan 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 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 dbeUmentation 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 1 have provided about this waste Is incorrect <br /> - This waste is from a tank which collects waste oil from household "dowWyourselft' (DIY) and/or conditionally exempt small" quantity generator (CESQG) sources. To the best of my <br /> knowledge, d In my DIY/ CESOG collection tank Is soley from DIY and/or CESQsources, have no <br /> the only waste oil contained rI ht mixed this waste oil with any other hazardous wastaQr waste oil <br /> € ffoln other sources. I agree to accept the additionai. charges. for, disposalof this waste.if the information ( have pro4lded about this waste is incorrect <br /> (All generators/ customers MUST read the following text <br /> 1 ;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 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 he/she has the authority to, bind customer, that the forgoing desetiptions'of waste <br /> and materials are true and accurate as packaged, marked, and labeled, are ready for .transportatiod in accordance with applicable state and federal regulations, and that customer shall abide <br /> by the Standard Terms. and Conditions on the reverse side of this Service Order. <br /> Service 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 1 <br /> oft eManifest prog hese fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> C1�tomer . Signa <br /> Ur <br /> Date . Driver . Signature Date <br /> UOVVk (A it, <br /> Print ninmpt Print Driver Name <br />