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., FOR SERVICE CALL: SERVICE ORDER DIXON OFFICE FORM N0, WOE5004•B (8118) ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER Nd. 1-800-727-2879 1f.ii�r'I'I FOR ACCOUNTING GALL: LMORLDOIL 5f 2-231-155Q ENVIRONMENTAL SERVICES,.. Poo a '3UZMAI�'S Ail l Q I10 AIR +�i+J'G[! 7300 CHEVRON WAY,DIXON,CA 85620 1-800-727-2679 ' 1(117 W Y''CSF II'i'I- AVE 1G:37 W YOasCMIFE AVE '. p WWW.WORLDOILCORP.COM ° MAIfi�k!' A, CA 9'5337 TRANSPORTER EPA#CA002827703fi MAN'i�yLCA,r�:A V,537 19 -` 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 OTY PIU TOTAL -;:.r��.�� ,11+1:�I:I �; �•+Fa ��f��,1 f l � �� ff 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 GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATED TSDF ^ II✓I' Fr�vl f: ilaF Wf KtELt'�f4 s j , +ts kl4f 31�t3D,r:FF.!` , r A g+�;",II F ALTERNATE TSDF: Rr,.rinq la'�dtlagrt' �Eft1 Rea-,f 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) V7)I hove not mixed any of the waste described above wlth any other hazardous waste,the total halide content Is LESS then 1,000 ppm,and she waste does not contain any PCBs.I have compiled with the requirements of the applicable Calilornle 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 i have provided about this waste Is Incorrect _ Q 021 have not mixed any of the waste described above with any other hexardous waste,the total halide content is GREATER then 1,000 ppm,and the waste does not contain any PCBs.1 have provided proper documentation to World Olt Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charge&for the disposal of this waste it the information)have provided about this wants Is Incorrect Q #3)This waste Is from a tank which collects waste oil from household"do-It-yourself'(D1Y)andlor condltlonatly exempt small quantity generator(CESOG)sources,To the best of my knowledge,the only waste air contained In my DIYI CESOG collection tank Is soley from DIY and/or CESOG sources,I have not mixed this waste ell with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal of this waste 11 the information I have provided about this waste Is Incorrect (All generators/customers MUST read the fallowing 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 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. y�J+l 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,thatthe forgoing descriptions of waste IIEIzlfit�l and materials are true and accurate ss packagod,marked,and labeled,are ready for transportation in accordance with applicable slate end federal regulatlons,and that customer shall abide (+t by the Standard Terms and Conditions on the reverse side of this Service Order. 1 Service Orders with an associated hazardous waste manifest(either aite specific or consolidated)are sublect to an EPA fee. These fees cover the EPA pass-threugh fee and administration of the eManlfest program, These fees very based on Manifest type. Applicable fees will appear on your b(ling Invoice. Customer Signature Date Driver Signature Date Print Name Print Driver Name