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tau.. FOR SERVICE CALL} ,SERVICE ORDER FORM NO.WOES0044{8/18) <br /> DIXON OFFICE.': ASBURY.ENVIRONMENTAL SERVICES, DBA <br /> E ORDER NO. <br /> 1•$00-727-287.9 - SERVIC <br /> r FOR,,ACCOUNTING CALL: 44WORLD OILf <br /> 562-231-1550 <br /> ENVIRONMENTAL-SERVICES- <br /> H �- 7300 CHEVRON WAY,DIXON,CA 95620 <br /> ` 1-800 727 2879 <br /> P QUE--ST RI lff�f�f ft Cx� i:f4 f4d':k <br /> P 'f <br /> N. CI".f;!'('f Al.. r 1rw WWW.WORLDOILCORP.0®M � ' It tfV � Tf l.�. �;f,il 1,.,4.20 <br /> E TRANSPORTER EPA#CAD028277036 <br /> (201 7k 14 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK#- CONTACT NAME' ORDER TAKEN 13Y HALIDES' <br /> HOME I. <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> -. �`�/ .'��/••,',(vl't-E,7 - CAI CZf,103 0;fir{5 <br /> PART# DESCRIPTION QTY ' UNIT PRICE QTY P/U TOTAL <br /> .. <br /> tf` I. i f `t1l L Y X.)L.;_ )I.UTION O a <br /> {o to /I tYS i1�7 ,.tfP-%l SUN!1-ilea°s BIATCH <br /> TOTAL <br /> CASH RECD: CHECK# t <br /> WASTE DISPOSAL.INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE CODE 2X1 <br /> ON=''RCRA HAZARDOUSWASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> 10 OTHER v <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: v:k Kt �: :, + al ,e s ti.• �. C:k c `r, . , ti .{.? •t i r r,�,: .t}l�{ `,gtr t7 ; <br /> Ff4bf"� r£Ealf. t {G{`� Pltlok <br /> , <br /> DRUMS P/U EMPTY DRUMS: . FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE. CHECK THE APPROPRIATE BOX) <br /> By signing below 1 hereby certify that: <br /> (Waste oil general.or/customer MUST check ONE of the following three boxes) <br /> Q #1)I have not mixed any of the 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 <br /> compiled with the requirements of the applicable California used oil management regulations to determine this Is true.11 agree to accept the additional charges for the.disposal of this waste if <br /> the Information I have provided about this waste is Incorrect <br /> Q <br /> #2],have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardouswaste.I agree to accept the additional <br /> charges for the disposal of this waste If the Information`I have provided about this waste Is Incorrect <br /> [] #3)This waste Is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my i <br /> knowledge,the only waste oil contained in my DIV/CESQG collection tank is soley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil l <br /> from other sources.I agree to accept the additional charges for disposal of-this waste if the Information I have provided about this waste Is incorrect 4 <br /> ), <br /> (All generators/customers MUST read the following text <br /> I certify that I have a program In placate reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal currently avallableto-me which minimizes the present and future threat to human life and the environment. <br /> 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,that the forgoing descriptions of waste <br /> and materials are true and accurate-as packaged,marked,and labeled,are ready for transportation in accordance with applicable state/an federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orc}eP with n associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee, Thes R esr o er tt� P pass-through fee and administration <br /> Of the eNla$sf st pr jram. These fee d a d on Manifest type. Applicable fees will appear on your billing invoice. <br /> C ®trier Signature Date Driver atyre ) Date <br /> Print Name Print Driver Name <br />