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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WORLD OIL 582-231-1550 <br /> ENVIRONMENTAL SERVICES- <br /> H <br /> S 7300 CHEVRON WAY. DIXON.CA 95620 <br /> 1 1-800-727-2879 <br /> P <br /> E WWW.WORLDOILCORP.COM <br /> 17 TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH REC'D: 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 /> DESIGNATED — <br /> ALTERNATE TSDF: - — — -- - <br /> DRUMS PIU,__ EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hens"certify ttm: <br /> n (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> u #1)1 have not mixed any of the wale described above with any other hazardous waste,the total halide content Is LESS than 1.000 ppm.and the waste does not contain any pates.1 have <br /> complied whit the requirements of the applicable callfornin used oil management regulations to determine this is true.I agree to accept the additional charges for the disposal of this waste if <br /> the lnbnmellon I have Provided about this waste is incorrect <br /> B #2 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is GREATER than 1,1100 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 hatnrdaus waste.I agree to aceapt 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 househoid-do-lt,yoursalf"(DIY)ondror corhditlonMly exempt small quantity generator(CESGG)sources.To the best of my <br /> knowledge.the only waste oil contained In my D1Yf CESOG collection tank Is coley from DfY and/or CESOG sources.I have not(nixed 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 thfs 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 /> praoticabfe method of treatment.storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. <br /> and 1rW�iare signing Int a space asset forth below on behalf of customer represents and wannonts that heishe has the authority to bind customer,that the forgoing descriptions of waste <br /> Packaged.marked,and labeled,are ready for transportation in accordance with applicable state 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 with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the*Manifest program. These fees vary hued on Manifest type. Applicable fees will appear on you,billing invoice. <br /> Customer Signature Date Driver Signature pate <br /> Print Name Print Driver Name — <br />