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FOR SERVICE CALL.: SERVICE ORDER <br /> DIXON OFFICE AS13URY ENVIRONMENTAL SERVICES, IBA FORM NO.wOES004-B <br /> 1-800-7-ASBURY <br /> SERVICE ORDER NO- <br /> P,ARL1 EfR <br /> 559-498-0240 <br /> CHICO <br /> 800-733-9043 WORLD OIL <br /> 5 <br /> ENVIRONMEN IAL SERVICES:. <br /> 1300 SOUTH SAN IA FECOMPTON CA 90221 <br /> I <br /> P LOS ANGELES OFFICE <br /> E 1-800-974-4495 <br /> D <br /> T TRANSPORTER EPA CAD028277036 <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> - b s <br /> HATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PARfi 7 DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OiLltvllXEC?OILS) I <br /> STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLl STATE CODE <br /> OTI-l _ <br /> DESIGNATED TSDF: <br /> ALTERNATETSDF: — <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> C�l f1)1 have not mixed any ofrite 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 requirements of <br /> the applicable California used oil management regulations to determine th Isis true.l agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is Incorrect <br /> =421 have not mixed any o{the waste described above with any other hazardous waste,the total halide content is GREATER than 1,0Q0 ppm,and the waste does nor contain any PCBs,I <br /> have provided proper documentation to World Cil Environmental SPrvlCea to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charges for the disposal or this <br /> waste ifthe information I have provided about this waste is incorrect <br /> =F3)This waste is from a tank which collects waste oil frorn household"do-ii-yourself"1CIly1 andlor conditionally exempt small quantity generator fCESOG)sources.To the best of my knowledae,the only waste oil contained <br /> in my DIY/Cl collection tanhis sr ley from DIY and,ror CESQG sources.I have not mixed this waste ail with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal <br /> of this Juste if the information!have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 25P4}If I am a large quantity generator,I certify that I have a program In place to reducethe volume and toxiaty of wa=re generated to the degree I have derermined to be economical€y practicable and that i have <br /> 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;Or,if I am a small quantity generator,i <br /> have made a good fairlh effori to minimize my waste generation and select the best waste manaoemPm method that is available to me that I can afford, <br /> This individual signing in the space set forth below on behalf of Cusiomec represents and warrants that he/she has the authority to hired Customer.that the forgoing descriptions of waste and materials are true and accurate <br /> as packaged,marked and iabaled,are ready for tran,portation in accordance with applicable state and federal regulations,andthat Customer shall abide and he pound by the Standard Terms and Conditions on the reverse <br /> side of this S-vic"brder. <br /> Customer Signature `Date Dritrer Signature` pate <br /> Print Name PrintQriyei`s Name - <br />