Laserfiche WebLink
OR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8/18) <br /> AXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> -800-727-2879 SERVICE ORDER NO. <br /> 70R ACCOUNTING CALL: WORLD OIL <br /> ;62-231-1550 <br /> ENVIRONMENTAL SERVICES- <br /> 7300 CHEVRON WAY. DIXON,CA 95620 <br /> 1-800-727-2879 <br /> W W W.WORLDOILCORP.COM <br /> S TRANSPORTER EPA#CAD028277036 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> GATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA It BILL of LADING/MANIFEST At <br /> PART# DESCRIPTION CITY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: 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 /> DRUMS PIU: EMPTY DRUM* '=+ _ FACILITY:_ _ 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 three boxes) <br /> Q all I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 ppmand the waste does not contain any PCBs.I have <br /> compiled with the requimments of the applicable California used oil management repulsions 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 /> [) 021 new not mixed any of the waste desenbed above with any other hazardous waste,the tocol halide content Is GREATER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to World 011 Environmental Services to recall 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 s alcorrect <br /> Q e3)This waste Is from a tank which collects waste oil from household"do-Il-yourself'(DIY)anNor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oll contalned In my DIY/CESOG collection lank Is soley tram DIY and/or CESOG sources.I have not mixed this waste all 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 reduce the volume and toxicity or waste generated to the degree I have determined to be economically practicable and that I have selected the <br /> practicable method of tremment,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,are ready for hanspodahon In accordance with applicable state and federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse aide of this Service Orde, <br /> Service Orders with an associated hazardous waste manliest(either site apeoflc or consolidated)are subject to an EPA Fee These tees cover the EPA passahrougn fee and administration <br /> of the nilest program. These tees very based on Manifest type. Applicable fees will appear on your billing Invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />