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FOR SERu,7E`SLE: SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA FORM NO.WOES004-D (1/17) <br /> 1-800-7-ASBURY SERVICE ORDER N0. <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 <br /> WORLD OIL <br /> 5 <br /> li 7300 CHEVRON WAY,DIXON CA 95620 <br /> 1-800-7-ASBURY <br /> WWW,WOR€ IDILCORPCOM <br /> D <br /> T TRANSPORTER EPA#CAD0282.77036 <br /> CUSTOMER# PURCHASE ORDER# ROUT[4-1 TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA; BILL of LADING/MANIFEST# <br /> PART# DESCRIPTIOfd QTY UNIT PRICE QTY P!U — TOTAL <br /> tl' <br /> r <br /> I <br /> IOTA L <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXFD OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ---� .�-----�—;=- _..-. .---=-,�--.,t. -.'. _ _•".. '..--._,= ;T.-;- ',.-:.`:T'--"i, '° i�.,.�"--L,.ins..`�93 <br /> ALTERNATETSDF: <br /> DRUMS P/U: EMPTY DRUMS: ___, FACILITY: BSC i <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that_ <br /> (Waste oil generator/customer MOST check ONE of the following three boxes) <br /> 9j9r11 I have not mixed any of the waste described above with any other iraEardow waste,the total halide content is LESS than 1.700 pP T,and the waste does not contain ariy PCBs-I have complied with the requirements of <br /> the applicable California used oil management regulations iu determine this is true 1 agree to accept the additi6r..al charges for the disposal of thio waste if the infomtation I have provided about this waste is incorrect <br /> 1=42l have not mixed any of the wa5te de:cribed above wiri-any other hazardous waste,the total halkle <br /> cOMNtt is GREATER than i,.060 ppm,and the waste does not contain any PCB<_.I <br /> have provided proper documentation to'T/orld 90 rnviran­en4 Services to rebut the pi esumption hat th-s waste was mixed Milo other hazardovs waste.I agree to:accept the additional charges for the disposal ofthis <br /> waste if the information I have provided about this waste is incorrect <br /> >�p31 This waste is from a tank which collects waste oil from household.:"do-it-yourseIf'(DIY)andor conditionally exempt small quanthy generator ICESQG}sources,to the best-of my knowledge,the only waste oil Contained <br /> In my DMCESQ(;collection tank Is saley from€71Y and/or CESgG scurcps.I have not mixed this waste oil with&ny other frazardous waste or waste oil from ether sources.I agree to accept the additional charges for disposat <br /> of this waste if the information I have provided ahovr.tti'i5 waste is incorrect <br /> (All generators/customers MUST read the foilowing text and check the associated box.) <br /> k i If I am a large quantity generator.I certify that I have a program in place to cedoce the volume-and tock l:y a`waste aenerated to the degree I have det�_rmined to be economically practicable and that k have <br /> selected the practicable method of treatment,.storage,or disposal currentiy available to me which minimizes th pr=sen¢and future threat to human lift and the environment;Cr,if I am a small quantity generator,I <br /> have made a good faith effort to minimize my waste generation and select the best waste management method that Is available to me that I can afford. <br /> This individual signing in the space set forth below on beFalf of Customer represnr:t5 and warrants that he/she has the authori tc bmd Customer,that the forgoing description=-of waste and materials are true and accurate <br /> as packaged,marked and labeled,are ready for transportation in accordance with apphca dle;tate and federal regulations,and thaE Custorner 5holl abide and tie bound by the 5tandard Terms and Conditions on the reverse <br /> side of this Service order <br /> y. s <br /> Customer Signature Date Driver Signature Date <br /> Print Name <br /> Print Drivers Name ' <br />