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--...FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING GALL: WORLD OIL 562-231-1550 <br /> ENVIRONMENTAL SERVICES— <br /> S 7300 CHEVRON WAY. DIXON.CA 95620 <br /> H <br /> 1 1-800-727-2879 <br /> P <br /> P WWW.WORLDOILCORRCOM <br /> E <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> Z7 [ 7ILI <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE OTY 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: <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 /> s1)1 have not mixed any of the waste described above with any other hazardous waste,the total hallde content is LESS than I.ODD ppm,and the waste does not contain any PCBs.1 have <br /> tl�Ig� the�auirements of the applicable Cellfomla used oil management regulations to determine this in true.I agree to accept the additional charges for the disposal of this waste If <br /> provided about this waste is incorrect <br /> Q #2 I have net mixed arty d thts wants described above with any other hazardous waste.the total halide content Is GREATER than 1.DDO ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentsom to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional <br /> CtMV a for the disposal of this waafw It the Information I have provided about this west*is Incorrect <br /> Q #3)Tttls wash Is from stank which cotlecta waste oil from household-do-it-yourself-(DIY)and/or conditionally exempt small qusrttty gerharator(CESOG)sources.To the best of my <br /> knowledge.the only was: oil contained In my flit!CESOG collection tank It solay from DIY and/or CESOG sources.I trove not mixed this watts tcall with any other hazardous Beate 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 watt*is incorrect <br /> (All generators/customers MUST read the following text <br /> I certfy 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 1 have se eata i the <br /> Practicable method of treatment.storage,or disposal currently avallawe to me which minimizes the present end future threat to human life and the environment. <br /> This lndtvldual signing In the apace sat forth below on behalf of customer represents and warrants that he/she has the authorlty to bind customer,that the forgoing descriptions of waste <br /> and"Materials we true and accurate as packaged,marked,and labeled.are ready for transportation in accordance with appHgbie state and federal regulations.and that Customer shall abide <br /> by On 34rKlard Terme and Cooditlons on flta reverse tide of fhb Service Order. <br /> of the a Asniforders with an m. Th ted w ver les arYla rrhanlftat{afflter site specific or consolidated)we subject to an EpA Fac, These teas cover the EPA pass-through tee and administration <br /> of the e6fanlfest program. Tftsaa foes yry beend an Limit type. Applicable lass will appear on your billing Invoice. <br /> Customer Signature Date _ Driver Signature Date <br /> r T f 0L <br /> Print Name Print Driver Name <br />