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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES00.1-E 8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER Na <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> r^'2-231-1550 <br /> `- ENVIRONMENTAL SERVICES- <br /> S 7300 CHEVRON WAY. DIXON,CA 95620 <br /> I 1-800-727-2879 Rt -0i1I ; iI .. ..t I II <br /> I L I <br /> P <br /> P i WWW.WORLDOILCORRCOM `rIKlI1�7, %A I <br /> E TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 r 1i.1 'IN i (;A fll3tiv <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> �. ,II}, € i � - � I .I rki ,! . t ;i � ' +ir r�•1 <br /> I <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST <br /> rf <br /> PART# DESCRIPTION QTY UNIT PRICE OTY PIU 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 /> *l r I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than t,000 ppm,and the waste does not contain any PCBs I <br /> compiled with the requirements of the applicable Callfornla used all management regulations to determine this Is true.r agree to accept the additional charges for the disposal of this t.a­ 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 PCB! <br /> have provided proper documentation to World Oil Environmental Services 10 rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the add dional <br /> charges for the disposal of this waste if the Information I have provided about this waste is incorrect <br /> [J #a)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 c., <br /> knowledge,the only waste all contained In my DIY/CESOG collection tank is soley from DIY and/or CESOG sources.I have not mixed this watts all with any other hazardous waste or wa n--il <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 <br /> 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 si lected 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 /> end 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 shat,ab-de <br /> h• the Standard Terms and Conditions on the reverse side of this Service Order. <br /> 'lc e 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 administrano.i <br /> _.ne:Manifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> / / / / <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />