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M P. <br /> e1 R <br /> Qb <br /> zCALL: SERVICE ORDER FORM NO.WOES004-B (8118) <br /> y ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> a w CCOUNTING CALLS <br /> y 31-1 550 WORLD OIL <br /> ENVIRONMENTAL_ SERVICES- <br /> { H +.yI.I:�MAH'S AUI�s REPAIR GU700: 730Q CHEVRON WAY,DIXON.CA 95620 <br /> 1-840.727.2879 <br /> P IU37 W (0,13EMITE AVF WWW.WORLDOILCORP.COM 1037 W YOSEMITE AVE <br /> +t, D MANTECA, CA 9533" TRANSPORTER EPA#CAD028277038 <br /> N4AL'dl•ECA, GR Intl6337 <br /> o i ll i* -d8i 9 12M) 239-18119 <br /> t CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> NMI 120 CA#.000440140 <br /> PART# DESCRIPTION OTY UNIT PRICE QTY PIU TOTAL <br />:+ OILY 4 CAL v W A i ER PER DRUM 1 tl� $�5U.sou <br /> 55-0rT 5!;GAL LON'Orr DRUM (RE"I"Of�dIT 0NED) 310 �I $%A2 <br /> EMS CMANIFE,% EPR r-[--.E ADIAIN -SITE SPECIFIC MANIFE T $ 5 OW 325'co <br /> t <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> J I NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL'MIXED OILS) STATE CODE 221 <br /> i NQN-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER:. <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> C'itis�t 5xr��#s r~:'calsru� � S<Irsl I4 <br /> QRUMS P/U:�� EMPTY DRUMS: FACILITY: BSC <br /> II GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> r _ 3 By algning below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> e 110 Q R1)1 have not mixed any of the waste described above with any other hazardous weal@,the total hellde content IS LESS than 1,000 ppm,and the waste does not contain any PC19a.1 have <br /> compiled with the requirements of the applicable California used oil management regulations to determine this Is true.I agree to eccepl the additional charges forlhe disposal oflhle waste If <br /> the Information I have provided about this waste Is incorrect <br /> y Q +21 he"not mixed any of the waste described above with any other haxardoue waal6,the total hallde content Is GREATER than 1,000 ppm,and the waste does not conteln any PCs*,t <br /> have provided proper documentation to World Oil Envl ronmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree 10 accept the additional <br /> charges for the disposal of this waste 11 the Inform6tlon I have provided about this waste 16 Incorrect <br /> 0 031 This waste is from a tank which collects waste oil from household"daft-youraelr(DIY)and/or conditionally exempt small quantity generator ICESOG)aourcea.To the best of my <br /> r knowledge,the only waste all contalnWh my DIV CESOO collection tank le coley from DIY and/or CESOG sources.I have not mixed this waste oil wkh any other hazardous waste or wants oil <br /> from other sources.I agree to accepl the additional charges for disposal of this waste 11 the i niormetloq I have provided about this waste Is Incorrect <br /> (All generators/customers MUST react the following text <br /> r I certify that I have a program In piece to Teduca the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have aaieeted the <br /> l 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 /> asLI■N This Individual signing In the apace sat fortis below on behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgcinsciestriptions of waste <br /> low end materials are true and accurate as packaged,marked,and labeled,are ready far transportatlan In eccnrdance wllh a ppllcable state and federal reguletion3,and theS customer shall ahlde <br /> by the Standard Terms/and Conditions on the rev ree aide of lhke Seryice Order. <br /> Service Orders with an` ssOClated h daui waste manifest{elthar Ilia specillc or consolidated)are sub}ect to an EPA Fee.Thane fees cover the EPA pass-through fee and adminlatradon <br /> of the eManlfesl proiiira T�eae f cry based on Manifest type. Applicable fees will appear on your billing invoice. _ <br /> Customek�i r�fre Date Driver Signature Date <br /> !'r r t! <br /> c <br /> i Print Name 5C W Print Driver Name <br /> r <br />