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FOR SERVICE CALL : SERVICE ORDER <br /> DIXON OFFICE FORM NO . WOES004- B (8/18) <br /> 1 -800-727-2879 ASBURY ENVIRONMENTAL SERVICES , DBA SERVICE ORDER NO . <br /> \ 231 - 1550 FOR ACCOUNTING CALL � WORLD OIL <br /> ENVIRONMENTAL SERVICESr <br /> H 7300 CHEVRON WAY, DIXON , CA 95620 <br /> 1 1 -800-727-2879 <br /> P <br /> E WWW, WORLDOILCORP. COM <br /> D TRANSPORTER EPA # CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER C'EPA # BILL of LADING/ MANIFEST # <br /> PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH REC ' D : CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON- RCRA HAZARDOUS WASTE , LIQUID ( USED OIUMIXED OILS) STATE CODE 221 <br /> NON- RCRA HAZARDOUS WASTE , LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER : <br /> DESIGNATED TSDF : _ r <br /> ALTERNATE TSDF : <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 /> {] #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 /> compiled with the requirements of the applicable California used oll 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 this waste Is Incorrect <br /> 0 #2 I 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 011 Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste. 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 /> Q #3) This waste is from a tank which collects waste oil from household "do-It-yourself" (DIV) and/or conditionally exempt small quantity generator (CESOG) sources. To the best of my <br /> knowledge, the only waste oil contained In my DIY/ CESOG collection tank Is soley from DIV and/or CESOG sources. I have not mixed this 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 about this 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 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 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 warrants that he/she has the authority to bind customer, that the forgoing descriptions of waste <br /> and materials Stands d Terms a d Conditions packaged. <br /> ncthe reverse marked,dof this Sed Ice Order. <br /> for transportation In accordance with applicable state and federal regulations, and that customer shall abide <br /> M; e ea Orders with an <br /> Manifes program.sThesef es vary based on Manifest(type. rsite Applicablelc or fees will appearon your Willing Invoiceare subject to an . <br /> Fee. These fees cover the EPA pass-through fee and administration <br /> Customer Signature <br /> Date Driver Signature Date <br /> Print Driver Name <br /> Print Name <br />