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SERVICE ORDER <br /> �R SERVICE CALL: <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA FC <br /> FC <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: � WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,. Nov 5, 2019 <br /> 7300 CHEVRON <br /> H ( ?+: IhIF'_,Ni `.;ii 16,10% f7C.Ii1(!:' 800-7 7DIXON,CA 95620 <br /> P {:, !I MAIN`;•I. JJ 1`I mrvl x r <br /> P WWW.WORLDOILCORP.COM <br /> ° Grl. TRANSPORTER EPA#CAD028277036 1vl�II,�.ITEGA, GA <br /> 9" <br /> T !ii <br /> 0 t ""25-4314.1 <br /> CUSTOMER # PURCHASE ORDER # ROUTE# TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> fh,ii_ > �� it If l/l.!1'thlf.l( �,fl'htltlllC'Z <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA 11 BILL of LADING/MANIFEST if <br /> 01130/210 t:•31�/Srl..OroNJnt�C;i . ? 0�� <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> "'I•i i ll I ..'I! .'; (.iFt+-JtL°l illi t;, 'f II ?I1 I+.}I'If l.'I I (•;',:' U!J ),, <br /> L;11�1141� L�IZ!1!<I; !.%t.1`t{(:. ;:�t•11,yr'lllt ra 1•t.,(•< 1�111.tJILi I �� tKll u�1 <br /> I.,l. I•►t;f�t-i, i=11-r�:l;:�s����rt r�la�►r•:i � �u��,; ;!�j / �-���t��i <br /> t.:(UI'_ t_1N—IA IIFI7SI' EI° , I 171__ Af.JI ilt l <br /> i71�)''f ({5t:l 11kr:.t t !d0 1;Ca'1_•�(:',t f,if r!I 1 'ltl i Flt'111 %1Iti( iAThfi IJEF1A-,n ts�1't:;19 f�. ....... ... . .. TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> FNON-RCRA <br /> CRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) STATE CODE,221 <br /> HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> R: <br /> NATED TSDF: <br /> NATE TSDF: nr ula'tr pl1ftnric?e�i. SIiIrt <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 /> Q #1)1 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 /> complied with the requirements of the applicable California used all management regulations to determine this Is true,I agree to accept the additional charges for the disposal of this waste If <br /> the Information I have provided about tills waste Is Incorrect <br /> zardous waste, <br /> le total <br /> e content Is <br /> Zmixed <br /> r documentation to World Oil En ironmenta Servlc sslt i <br /> TER than <br /> m,and the <br /> te <br /> not <br /> n any <br /> to rebut he p esat <br /> umption thathis waste s mxed with h0er0zhaardous wasteeI agreeeiB <br /> to accept th add o <br /> hhavep ovlded proper nal <br /> charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect <br /> Q #3)This waste Is from a tank which collects waste oil from household"do-it-yourself"(01Y)and/or conditionally oxompl small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIY/CESOG collection tank Is soloy from DIY and/or CESOG sources.I have not mixed tills waste oil with any other hazardous waste or waste oil <br /> from other sources,I agree to accept the additional charges for disposal of this waste If the Information I have provided aboul'Ihls waste Is Incorrect' <br /> (All generators/customers MUST read the following text <br /> I certify that I have a program In place to reduce the volume and toxicity of waste genoratod 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 to 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 warrant Ihot he/she has the authorlly to bind customer,that In In accordance with applicaha forgoing descriptions of waste <br /> Is material s are true and accurate are packaged,marked,and labeled,are ready,lor transportatioble stela and federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orders hkth an essoclatad hazardous waste manifest(either site specific or consolidated)are subject to an EPA Feo. These fees cover the EPA pass-through fee and administration <br /> f th00 nit st ggrem. These fees vary based on Manifest type. Applicable lees will appear on your billing Invoice. <br /> Customer Signature Date - r,,/°>l' Driver Signature Date <br /> Print Name)— >,: :' 1`PrInt DrIver'Name <br />