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� 7 <br /> rt - s <br /> FOR SERVICE CALL : SERVICE ORDER FORFA NO . WOES004- B (8118 ) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA SERVICE ORDER NO, <br /> 11800.727-2879 <br /> rd3118152 <br /> FOR ACCOUNTING CALL : WORLD OIL <br /> 562-231 . 1550 <br /> ENVIRONMENTAL SERVICES ~ <br /> S 7300 CHEVRON WAY, DIXON, CA 95620 <br /> ", TRACY TOYOTA - NORTH NAGLEL RD 1 - 800 - 727- 2879 <br /> E It'W5 NORTH NAGLEE ROAD WW W.WORLDOILCORP. COM 2895 NORTH IJAGLEE ROAD <br /> D TRANSPORTER EPA # CAD028277036 <br /> T TRACY , CA 95304 TRACY, CA, 953 ' 8 <br /> o ( 2(1 )1 83A 1111 120Q) 5341 1111 <br /> CUSTOMER N PURCHASE ORDER M ROUTE p TRUCK M CONTACT NAME ORDER TAKEN BY HALIDES <br /> lr1U iT OB f 111E J rEIR C+d SRIHI : INu ,;i ILL iULL- 3-1 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA 9 BILL of LADING/ MANIFEST X <br /> PART M DESCRIPTION CITY UNIT PRICE OTY P/L1 TOTAL <br /> UStu ;v1rTt+ L (AL AHL) c,, .ASOLINE FILTERS <br /> ('SIL FILTER DRUM REPLACEMENT - NO CHARGE / <br /> croPIES of SERVICc CTRnEFi i " r l F=II Gray leave 3 f ril+r_ernMts vilim er . <br /> TOTAL <br /> CASH RECD ; CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER : I ' if ( ' i kin n l , ,ia r s t 11111: 41 It r-ru. r I.ut . ' ' lit ) - - - <br /> DESIGNATED TSDF: ANIFRICAN VALLEY WASTE OIL 521 INDUSTRIAL DR , ltw . LIVIiN <br /> ALTERNATE TSDF : <br /> ^ FE Cr kEF'LC: �;if ITS+ ' CdL TArIIK6z; E ' K <br /> DRUMS P/U : J—/ EMPTY DRUMS : FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> Sy signing below I hereby certify that- <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Q al) 1 have nor mixed arty 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 sr.y PCBs . I have - - <br /> compiled v inh the requirements of the applicable California used oil management regulations to determine this Is true 1 agree to accept the additional charges for the disposal of this waste It <br /> the information 1 have provided about this waste Is Incorrect , <br /> 0 a2 1 have nor mixed any of Ilia waste described above with any other hazardous waste. the total hillde content Is GREATER than 1 ,000 ppm. and the waste does not contain any PCBs. I <br /> have provided proper documentation to World Oil Environm"dar Services to rebut the presumption that this waste was mixed with Omer hexardous waste. I agree to accept the additional <br /> charges for the disposal of this waste it the Infarmstlon I have provided about this waste is Incorrect - <br /> 0 a)) This waste Is from a tank which cofecle waste oil from householddo-ll-youraell (DIV) and/or conditionally exempt small quantity generator CESOG) sources . To the best of my �•;, �1 <br /> knowledge, the only waste oil contained In my DIV/ CESOG collection tank Is soiey from DIY andfar CESOG sources. I have not mixed this er"It oil with any other huerdous "sate or waste oil <br /> from offs sources. 1 agree to accept the additional charges for disposal of this waste if the Information 1 have provided about this waste is Incorrect <br /> (All generators/ customers MUST read the following text <br /> 1 certify that I have a program In place to reduce the volume and toxicity of waste generated to Ilia degree f have deleimined to be aconomtcelly practicable aro that 1 have selected Ilia <br /> Practicable method of treatment, storage, or disposal currently available to me which mtnlmleaa the present and tulure threat so human tile and the environment. <br /> This Individual signing In the space set forth below on behalf of customer represents and warrants that heiShe has the authority to bind customs, that Ue forgoing descriptions of waste <br /> andon he ease sof Ihta <br /> material$ eve true and accurate as marked, <br /> ttle bolede am a inside for transportation In accordance with applicable state and federal reguiatio ia, and that customer %hall abide <br /> re tthe Standard Terms and Conditions <br /> Ssvice Orders with an &lacerated hazardous waste manifest terther site spacllic or consolidated) are subject to an EPA Fee. These fees rover the EPA pass-through lee and administration <br /> Of the eManlfest program. These fees vary based on ldanifast type. Applicable fees will appear on your billing Invoice. <br /> L It if <br /> Customer Signature Date Date <br /> g Driver Signature Date <br /> it <br /> T <br /> Print Name Print Driver Name <br /> t <br />