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" FOR SERVICE CALL : SERVICE ORDER DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES DBA FORM N0. WOES004-[3 (8118) 1400427w2879 SERVICE ORDER NO. FOR ACCOUNTING CALL : "� N2942528 562-231 -1550 WORLD OIL S ENVIRONMENTAL SERVICESw H TRACY FORD - 2311695 7300 CHEVRON WAY, DIXON, CA 95620 P 3500 AU i"O Pi.,AZA WAY1 -800-727-2879 i= WWWaWORLDOILCORP.COM 3500 AU f 0 PLAZA WAY o r TRACYCA 95304 TRANSPORTER EPA # CAD028277036 o ;2t) ) 'u3a-�EC� 'i 1 'hACY, CA !D5304 (200) 8354821 CUSTOMER # PURCHASE ORDER # : ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES 13 '169 Nl `: 'i Ot�'f EIIN F.- Fi �� SiVI �•i, Sn �� tln>�z DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # 7I2f?a19 Cf1l,.0Ga35'I 1 53 PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL EMS E iAN FEST EPA FE � ' A IVI1N - SITE SPIE :IFIL. IV AN F V i 1 r •, 11111.3CEC� 1'vil)CEfO FUELS PER DRUM ' ' U U ;t, 1U. 0 $2254600 12a. . oa 55 • C'/Ti1 55 GALLON CIT tMETAL DR( IM 1 "� G . OG $O. GO BATCH to TOTAL CASH RECD : CHECK # WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQ1 ID I USED OIL/MIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE , LIQL ID I ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER . DESIGNATED TSDF: ALTERNATE TSDF• DRUMS P/ EMPTY DRUMSFACILITY: BSC �r � GENERATOR WA TE CERTIFICATION (PLEASE CHECK THE APPROPRI TE BOX REVD By signing below I hereby certify that: (Waste oil genet or customer MUST check ONE of the following threlue [] #1) 1 have not mixed any of the waste described above with i rty of ter hazardous waste, the total halide content Is LESS than 1 ,000 complied with the requirements of the applicable California us oil umagement regulations to determine this is true. I agree to accept he additional charges form, and the waste doestthe disposcontain al of this waste if the Information I have provided about this waste Is Incorrect Q #21 have not mixed any of the waste described above with a iy oiler hazardous waste, the total halide content is GREATER than 1 ,000 ppm, and the waste does not contain any PCBs. 1 have provided proper documentation to World Oil Environment I Ser tices to rebut the presumption that this waste was mixed with other hazardous waste, I agree to accept the additional charges for the disposal of this waste If the Information I have F ovid id about this waste Is Incorrect 0 #3) Title waste is from a tank which collects waste oil from It usel old "do•it•yourself" (131Y) and/or conditionally exempt small quantity generator (CESQG) sources. To the best of my knowledge, the only waste oil contained In my DIY/ CESQG coil ctlor tank Is soley from DIY and/or CESQG sources, l have not mixed this waste oil with any other hazardous waste or waste oil from other sources. I agree to accept the additional charges for 'jispc set of this waste if the information 1 have provided about this waste is incorrect (Ail ge er tors/ customers MUST read the following text I cerrify:(hat I have a program in place to reduce the volume anc toxl ty of waste generated to the degree I have determined to be economically practicable and that 1 have selected the practidable method of treatment, storage, or disposal currently valla le to me which minimizes the present and future threat to human life and the environment This individual signing in the space set forth below on behalf of cuaft mer represents and warrants that he/she has the authority to bind customer, that the forgoing descriptions of waste and materials are true and accurate as packaged, marked, and I belet 1, are ready for transportation in accordance with applicable slate and federal regulations, and that customer shall abide by the standard Terms and Conditions on the reverse aide of th Ser Pice Order. Service Orders with an ass ted hazardous waste manifest (e her Its specific or consolidated) are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration of the eManifest pro he a fees vary based on Manifest tylKlo Applicable fees will appear on your billing Invoice. iusto er Signature Date2 `1 Signature Date Prin ame tint Driver Name