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Fte SERVICE CALL: SERVICE ORDER DIXON OFFICE A BURY ENVIRONMENTAL SERVICES , DBA FORM NO. WOES004- B (4/17) 1 -800- 727-2879 SERVICE ORDER NO, FOR ACCOUNTING CALL : 562-231 - 1550 WORLD OIL FEB ENVIRONMENTAL SERVICES ,t., S7300 CHEVRON WAY, DIXON CA 95620 H 1 -800- 727-2879 - P WWW. WORLDOILCORP. COM F IN D TRANSPORTER EPA # CAD028277036 CUSTOMER # PURCHASE ORDER # ROUTE # yyTRjUCK # CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/MANIFEST # ', ; f � } } PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL c n. . . . OTAL CASH RECD : CHECK # WASTE DISPOSAL INFORMATION MON - RCRA HAZARDOUS WASTE, LIQUID ( USED OIL/MIXED OILS) STATE CODE 221 MON- RCRA HAZARDOUS WASTE, LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER : DESIGNATEDTSDF: : ;° ALTERNATE TSDF : DRUMS P/U : EMPTY DRUMS : FACILITY: BSC GENERATOR \NASTE CERTIFICATION ( PLEASE CHECK THE APPROPRIATE BOX) By sig Ing below I hereby certify that: - f ( Waste oil generator/customer MUST check ONE of the following three boxes ) p'41 ) 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) have complied 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 the information I have provided about this waste is incorrect = #2 1 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 have provided proper documentation to world Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste. I agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is incorrect = 43) This waste is from a tank which collects waste oil from household "do-it-yourself' (DIY) and/or conditionally exempt small quantity generator (CESQG) sources. To the best of my knowledge, the only waste oil contained in my DIY/ CESQG collection tank is soley from DIY and/or CESQG sources. I have not mixed this waste oil with any other hazardous waste or waste oil from other sources. I agree to accept the additional charges for disposal of this waste if the information I have provided about this S,vaste is incorrect I (All generators/ customers MUST read the following text and check the associated box .) 'MN ) if Ian) a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined tobe7oconormically practicable and that I have .'selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human life and the eniftrorgthent Or, if I am a small quantity generator, I 1 have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me that I can afford. 2 IN S, �' j�. 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, thaYthe forgoing descriptions of waste 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 app be.pound by the Stan6rd Terms and Conditions on the reverse side of (his' Service Or er. r =`g ^° a'' ISIS It j Sr INALf IS NA, Custom r :Signature ; Date Driver Signature Date NINe b — , .r Print Name Print Drivers Narne