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FOIA 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 OHL ENVIRONMENTAL SERVICES. S 7300 CHEVRON WAY,DIXON,CA 95620 NI i _ " 1-800-727-2879; I , WWW.WORLDOiLCORP.COM P „d D TRANSPORTER EPA#CAD028277036 T ., 21 cl .a .°3 O CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL I t',+E BI L t' 7 ;ayes ry�•.+°, ttl �t I .i: i, ra."(,atii I�, ,*ie`'i,. a,l.;t If(;, t' ''f TOTAL CASH.REC'D: . ? CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID:(USED OIL/MIXED OILS) STATE CODE 221 77 NON?RCRA HAZARDOUS WASTE,'LIQUiD(ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATED TSDF: ALTERNATE TSDF: _ 3i DRUMS P/U: EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) dy signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) Q'J11)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 with the.requirernelpts of the applicable California used oll management regulations to determine this is true.1 agree io accept the additional charges for the disposal of this waste It the information I have provided about this waste Is incorrect Q'.#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 contaln'any PCBs.1 have provided proper documentation to World Oil 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 informationI have provided about this waste is incorrect Q! 43)Thls waste Is from a tank which collects waste oil from household"do-it-yourself"(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my knowfedge,the only waste oil contained In my DIY/CESOG collection tank Is soley from'DlYand/or!CESOG sources.I have not mixed this waste oll with any other hazardous waste or waste oil 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 {All generators/customers MUST read the following text I m certify that(have a prograin 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 practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. This Individuagnin 'In the space set fackagedmarkedand labeledare ready for transportation n accordance orth below on behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgoing descriptlons of waste and materiall sls aro true gand accurate se p , , , with applicable state and federal regulations,and that customer shall abide by the Standard Terms and Conditions on the reverse sideof this Service Order. Service Orders 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 9k3[te' Manifest progre These fees vary based on Manifest type.Applicable fees will appear on your billing invoice. .....CustorrlEr: Ignature Date Driver Signature Date Print Name Print Driver Name