Laserfiche WebLink
FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-.B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> N2902081 <br /> FOR ACCOUNTING CALL: i <br /> 562-231-1550 "WORLD OIL <br /> ENVIRONMENTAL SERVICES,M <br /> s 7300 CHEVRON WAY,DIXON,CA 95620 <br /> " FIRESTONE#356612 1-800-727-2879 QUEST RESOURCE MGT- FIRES' <br /> P9401 N, CENTRAL AVE 6175 MAIN STREET, SUITE 420 <br /> WW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> TRACY, CA 05376 FRISCO, TX 75034 <br /> T (209)271-7164 (072) 464-0004 { <br /> r. <br /> CUSTOMER.# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> (—li $69 13FRC356612 OER 8h SIT! <br /> zo iq _ <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 5/21/2019 CAL000370396 <br /> PART# DESCRIPTION QTY UNIT PRICE `QTY P/U TOTAL <br /> OILYW OILY WATER PER RUM 1 �� <br /> 55-C/TN 55 GALLON C/T METAL DRUM "I <br /> EMS EMANIFEST EPA FEE&ADMIN-SITE SPECIFIC'MANIFES 1l <br /> :�0 <br /> OPEN M- 44PM SAT 7--6PM St1N 9-GPM BATCH#, i, <br /> Z193 TOTAL <br /> CASH REC'Dc CHECK'# <br /> j h <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED.Ott./MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)" STATE CODE _ <br /> OTHER: <br /> DESIGNATED TSDF:" <br /> ALTERNTE TSDF:•- <br /> CYCtSS" t t:L'4: 000U E a5age; c3arr oa' I <br /> ri <br /> DRUMS P/U EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE SOX) ' <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following threw boxes) <br /> 0 #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 PC8s.1 have <br /> compiled with the requirements of the applicable California used oil management regulations to determine this is true.I agree to accept the additional oh ea for the disposal of this waste If <br /> the Information]have provided about this waste la Incorrect <br /> 0 #21 have not mixed any of the waste described above with any other hazardous waste,the total halide content 1s GREATER than 1,000 ppm,and the snta dooa not cont In Ony P08s,1 <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous we o.Ing r R igi� Q� <br /> charges for the disposal of this waste If the Information I have provided about this waste is Incorrect "j I *o dl <br /> Q #3)This waste is from a t@nlCwhlolloolioots Waato oil from Household!'do•it yoursolC"(DIY)acid/or cond►tlonally exompt small%qupnllty goner tor(C ���ggources,To the best of my i <br /> knowledge,the only;waste olbcoritained In my©lY/CEM oolteaflon tank le eolay from,DIY*V0r,CES0G saarces.I h80 net mixed this Waste oIl with t)b$r l�lq�pfr)pj{H,y a2 atwaste oil <br /> from other sources. agree ta:accept the nddigbna)charges�tnr:disposai;oithls waste If.tha Infattitkaticn hhovs pidv.Ide`d Ub6 i##wa(to la ihoorroot <br /> (Ali generators/customers MUST read the following text I. <br /> 1 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 <br /> practicable method of treatment,storage,or disposal currently available tome which minimizes the present and future threat to human life and the environment. <br /> Thio individual slgd[ng imlhe.apace est to h'bstow an bdhnit of-oastomer,mprosents and,wnrranlethai hetehe has the authority to bind customer,that the torgoln8 descrlpilons of waste <br /> and motorists arotrba end aceatate as-pso aged„tnarkod+and•teooled;ate toady for transp111,1; oh In aaoord.4gde with applicable sato ehd fedaral regulations,and that customer shall abide <br /> by the Stondardloft0b attd Conditiana b0ho reverse side Mhls:ftoW�ce t7rdor, <br /> Service Cr wl tan assoclated hazardous waste ManifosII(either altaspegific or consolidated)are subject to an EPA Fee.TI a tees cover the EPA passdhrough fee and administration <br /> of the aM1 frost p ogram.These fees.V Mahltseftypo Appilonbietses will,appear on your billing Invoice. <br /> S” nature: Date" Clriver Signature Date <br /> Prtnf{N e t?rl6t Driver Name <br />