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FOR SERVICE CALL. SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRON .=NTAL SERVICES, DBA FORM NO. WOES004-B (8/18) <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL; <br /> 562-231-1550 WORLD O I L <br /> ENVIRONMENTAL SERVICES.,, <br /> s <br /> 7300 CHEVRON WAY, DIXON,CA 95620 <br /> P 1-800-727-2879 <br /> E WWW.WORLDOILCORP.COM <br /> ° 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 <br /> CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> CASH REC'D: TOTAL <br /> _ CNECIC# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS STATE CODE 221 <br /> OTHER: ) STATE CODE <br /> DESIGNATED TSDF: - <br /> ALTERNATE TSDF: - - — - <br /> DRUMS P/U: _ EMPTY DRUMS: FACILITY:. <br /> 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 <br /> [) #1)I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than},000 three boxes) <br /> Compiled with the requirements of the applicable California used oil management regulations to determine this is true.I agree to accept he additional charges for the d she waste does not conta�poany sal of h s waste if <br /> the information I have provided about this waste is incorrect <br /> [3 #2 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1,040 ppm,and the waste does not contain any PCes.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 /> [l #3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity <br /> knowfedge,the only waste oil contained in my DIYf CESOG collection tank is soley from DIY and/or CESQG sources.I have not mixed this generator waste oil with any otherrhazarTo e best of <br /> dous waste ornwaste all <br /> from other sources.I agree to accept the additional charges for dlsposal of this waste if the information f 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 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 descriptions of waste <br /> and materials are true and accurate as packaged,marked,and labeled,areready for transportation 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 passthrough fee and administration <br /> of the eManffest Pregram. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date <br /> Driver Signature Date <br /> Print!Name <br /> _�i,_ Print Driver Name - <br />