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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-8(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> ' <br /> FOR ACCOUNTING CALL: 2989322 <br /> ()WORLD <br /> OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,. <br /> TEC OF CALIFORNIA-LOUISE AVE 7300 CHEVRON WAY,DIXON,CA 95620 <br /> i 2050 E LOUISE AVE 1-800-727-2879 2050 E LOUISE AVE <br /> P WWW.WORLDOILCORP.COM <br /> LATHROP,CA 95330 TRANSPORTER EPA#CAD028277036 LATHROP., CA 95330 <br /> T (209) 858-4110 (209)858-4110 - <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES' <br /> DATE REQUIREDI DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/.MANIFEST#• <br /> PART# DESCRIPTION' QTY UNIT PRICE. QTY P/U TQTAI. <br /> OFDR OIL FILTER DRUM REPLACEMENT- NO CHARGE 2 $0.00 � $0.00 <br /> BATCH <br /> TOTAL ' <br /> CASH REC'D: CHECK <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCQA_fJ •Y••RPOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA-HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: NON-RCRA HAZARDOUS WASTE,SOLID(FILTERS CONTAINING OIL)STATE CODE 223YES MANAGEMEN <br /> DESIGNATED TSDF: AZ <br /> AI,.TERSam Read <br /> rOSS E T DF: <br /> DRUMS-P �,.;:�-r:r EMPTY DRUMS: 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 11)1 have not mixed any of the waste described above!n"any other hazardous waste,the total halide content Is LESS than 1.000 ppm,and the waste does not contain any PCBs.i have. <br /> compiled with the requirements of the applicable Calltornla.nsed oil management regulations to determine this Is true.I agree to accept the additional charges for the disposal of thisaisle if. <br /> the tnformatlon I have provided about this waste is incorrect <br /> 0 #21 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 Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.l agree to accept the additibrfal <br /> charges for the disposal of this waste If the information I have provided about this waste is Incorrect <br /> Q #3)This waste Is from a tank which collects waste oil from household"do-ft-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the beat of my <br /> knowledge,the only waste oil contained In my DIY/CESQG collection tank is soley from DIY and/or CESQG sources.t have not mixed this waste oil with any other hazardous waste or waste all <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 /> (Ali 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,are ready for transportation In accordance with applicable state and federal regulations,and.that customer shall abide <br /> by.lha Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either stte specific or consolidated)are subject to an EPA Fee.Tt ees c r the EPA pass-through fee and administration <br /> of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing Invoice. <br /> A /9 1& <br /> b&Z_ 4?'l <br /> Cus er ign re pDate M r g-nature Date <br /> A Pu a�r lI tOL <br /> C? ` <br /> Print N e Print Driver Name <br />