Laserfiche WebLink
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 /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES. <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H 1-800-727-2879 <br /> I <br /> P WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> E <br /> T f <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 OTY 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: T <br /> ALTERNATE TSDF: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below 1 hereby certify that. <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 al)1 have not mixed any of the waste described above wllh any other hazardous waste.the total halide content ie 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 INs Is true.I agree to accept the additional charges for the disposal of this waste If <br /> the Information 1 have provided about this waste is incorrect <br /> CI z21 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.1 agree to accept the additional <br /> charges for The disposal of this waste It the Information I have provided about this west.Is Inconecl <br /> I] 13)This waste is from a bank which collects waste oil from household"do-h-yourself (01Y)anNur conditionally exempt small quantity generator CESOG)sources,To the best of my <br /> knowledge,the only waste all contained in my OIY1 CESOG collection tank is relay from OIY and/or CESOG sources.1 have nor 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 11 the Information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text <br /> I Cenily that I have a program in place to reduce the volume and toxicity of waste generated to me degree I have derermmeel 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 at customer represents and warrants that he/she hes Me authority to bind customer.that the forgoing descriptions of waste <br /> and materials are true and accurate as packaged.marked,and labeled.are ready lot transportation in accordance with applicable stale and federal regulationsand that customer shall abide <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orders with an assozated hazardous waste mantled nathet site specilla or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the eManlfest program. These lees vary based on Menli l type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />