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FOR SERVICE CAj.—il SERVICE ORDER <br /> DIXON OFFICE ASBURY fl iYIRONMEi TAT SERVICES, DBA FORM NO.WOES004—B (1/17) <br /> 1-800-7-ASBURY � F SERVICE ORDER NO. <br /> FOP ACCOUNTING CALL: <br /> 552-231-1550 <br /> WORLD OIL <br /> ENVIRONMENTAL SERV#CES;:, <br /> 7300 CHEVRON WAY,DIXON CA 95620 <br /> o 1-&00-7-A S BU RY <br /> P <br /> o INWW:WORLD01LCQRP,C0M <br /> T TRANSPORTER EPA#CAD028277fl36 <br /> 6 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY <br /> HALIDES <br /> t <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMFR EPA# BILL of LADIgNG/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> v <br /> TCtTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS} STATE CODE <br /> OTHER: _ <br /> DESIGNATEDTSDF:� # .:.35 'aanl'..=7�.rgs E;AK�1G: it31 <br /> ALTERNATE TSDF: <br /> DRUMS PfU: _ EMPTY DRUMS:__ FACIl BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> Ry signing bei I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> .Offl,"-I}I have not mixed any of the waste described ahove with any Other hazardous waste,the total haiide content is LESS khan.,000 ppm,and the waste does not contain any PCBs.I have complied with the requirements of <br /> The applicable Califomia used oil management fegoiations to determine this is true-I agree to accept the additinna€charges for the disposal Of this wasae if the information i have provided about t11.i5 waste is incorrect <br /> =02 1 have not mixed any ofthe waste described above with any other hazardous waste,the total halide content is CREAtER than 1.000 ppm,and the does not contain any PCBs.I <br /> have provided proper documentation to World Oil Env400mental Services to rebut the pre,wnption that this a5te was mixed vdith ether hazardous waste-I agree to accept the additional charges for the disposal of this <br /> waste if the information I have provided about this waste is incorrect <br /> 1=43!This waste is from a tank which collects haste oil fmin househeid"do-ir-yaurselP iDIY1 and/orcondhtionally exempt small quantity generator ICESQG sources.To the best of my knowledge,the only waste oit contained <br /> it my DIV CESQG collection tank is soley from landior CESQG sources.I have not mired this waste oil wick any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal <br /> of this waste if the information I have provided about this waste is incorrect <br /> (Ail generators/customers MUST read the following text and check the associated box.) <br /> x4)If I am a large quantity generator,i certify that,have a program in place ro reduce the volume and toxicity of vmste generated to the degree I have determined to be economically practicable and that I have <br /> selected the practicablemetttod 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 faith effort to minimize my waste,eneratfun'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 beha if of Customer represents-and warrants that helshe has the authority to bind Customer,that the€crgcing descriptions of waste and materials are true and accurate <br /> as packaged,�ark¢%and labeled,are ready fortransportatlon in accordance with applicable state and federal ragWaitions,and thgrCustomer shall abide and be bound by the Standard terms and Conditions on the reverse <br /> side ofthis set I., Older. <br /> Customer <br /> Driver Signattur s Date <br /> PrsntName Printpflarets�N me <br />