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OR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8/18) <br /> IIXON OFFICE ASBURY ENVIRONMENTAL SERVICES. DBA <br /> -800-727.2879 SERVICE ORDER NO. <br /> :OR ACCOUNTING CALL: V1lORLD OIL <br /> 62-231-1550 <br /> ENVIRONMENTAL SERVICES. <br /> 7300 CHEVRON WAY,DIXON, CA 95620 <br /> 1-800-727-2879 <br /> WW W.WORLDOILCORP.COM <br /> TRANSPORTER EPA# CAD028277036 <br /> T <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 PN:_ EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby cannily met. <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Q sti I have not mixed any of the waste described!above with any other hazardous waste,the tool halide content Is LESS than 1.000 ppm,and the waste does not contain any PCBs.I have <br /> compiled with the requirements of tae 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 /> 12 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.t <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 it the Information I have provided about this waste Is Incorrect <br /> 0 e3)This waste Is from a lank which collects waste oil from household"do-d-yourself (DIY)and/or conditionally 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 DIY and/or CESOG sources.I 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 Ia 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 lite and the environment. <br /> This individual signing in the space sal forth below on behalf of customer represents and warrants that hwshe has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurate As Psdkege ,marked,and labeled,aro reedy for transportation in accordance with applicable state and federal regulations.and that customer shall abide <br /> by the Standard Terme and Conditions on Otis reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site specific or consoimaled)are subject to an EPA Fee. These lees cover the EPA pass-through fee and administration <br /> al the eManileM program. These fees vary,based on Manifest type Applicable bee will appear on your billing Invoice. <br /> -/ / 1-2 <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />