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DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA SERVICE —ORDER NO. <br /> " <br /> 9 _az,7n-727.-2879 <br /> FOR ACCOUNTING CALL : <br /> 562-231 — 1 550 WORLD OIL <br /> a z' 2a19 <br /> ENVIRONMENTAL SERVICELI <br /> S 7300 CHEVRON WAY, DIXON , CA 95620 <br /> 1 1 -800-727-2879 <br /> P I LWWW.WORLDOILCORP. COM <br /> � 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 OTY P/U TOTAL <br /> _ . <br /> TOTAL <br /> CASH REC ' D : CHECK # T <br /> WASTE DISPOSAL INFORMATION <br /> NON - RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) STATE CODE 221 <br /> NOWFICRA 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 SOX) <br /> By signing below 1 hereby certify that: <br /> (Waste oil generator/Customer MUST Check ONE of the f011OW1ng 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 /> compiled with the requirements of the applicable California 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 information I have provided about this waste Is Incorrect <br /> Q #21 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. 1 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' (DIY) 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 DIY and/or CESOG sources. I have not mlxed 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 /> (Ail generators/ Customers MUST reed 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 are true and accurate as 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 eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />