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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER No. 1-800 727-2879 FOR ACCOUNTING CALL: 562-231-1550 WORLD OIL ENVIRONMENTAL SERVICES- S- 7300 ERVICES.s 7300 CHEVRON WAY, DIXON,CA 95620 79, P WWW.WORLDOILCORP.COM E TRANSPORTER EPA#CAD028277036 f CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES '� a, ) .`6 & ire' L ,e. l,a...i ate ask, rlllt f a DATE REQUIRED '. DATE ENTERED NEXT SERVICE DATE" CUSTOMER EPA# BILL of LADING/MANIFEST# PART#i DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL N 14 Ix, i`er,jx c, l4411s 1R) I.r'zt l ) il;,l':3( (i('" #dw'i"':+Ir «',, # r3,t,q s k ,r. TOTAL CASH RECD: CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE,LIQUID:(USED OIL/MIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOLSOLUTIONS) STATE CODE OTHER: ' t DESIGNATED TSDF: ALTERNATE'TSDF: i DRUMS PIU: + EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) By signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) [] #1}I have,not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 ppm,and the waste does not contain any PCBs.I have complied wtth the requirements of the applicable Californla used oil management regulations to determine this is true.I agree to accept the additional charges for the disposal of this waste if the information,(have provided-about this waste is Incorrect Q 421 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than,1,00D ppm,and the waste does not contain any PCBs:I 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 charges for the disposal of this waste If the information)have provided aboufthis waste':is Incorrect Q 'h)Thls waste Is from a tank which collects waste oil from household"do—it—yourself"(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my knowledge,the onty waste oil contained in my DIY/CESQG collection tank Is soley from DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste orwaste all fromoiher sources.I agree to accept the additional charges for disposal of this waste If the Information 1 havej'provided about this waste is incorrect (All generators/customers MUST read the following text 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 than have selected the practicable method of treatment,storage,or disposal currently available tome 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 customer 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 labeled,are ready for transportation.in accordance with applicable state and federal regulations,and that customer shall abide byfhe Standard Terms and Conditions on the reverse side of this Service Order. „,.„—Smift,Arders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee, These fees cover the EPA pass-through fee and administration o th "eM nlfest pro grattl-These fees vary based on Manifest type. Applicable fees wlh appear on your billing involce. 1-1-Qustomer Sigr'�atur Date Driver Signature Date ully i Print Name Print Driver Name