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FOR SERVICE CALL : SERVICE OR R FORM N0 , WOES004-B (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL RVICES DBA <br /> 1 -800-727-2879 ° SERVICE ORDER NO. <br /> s <br /> FOR ACCOUNTING CALL : �� � � ' � <br /> 562-231 - 1550 <br /> ENVIRONMENTAL S rA� <br /> ES .,a <br /> 7300 CHEVRON WAY, NX0 95620 <br /> I111 : , . 1 .800-727-2879 <br /> s <br /> 5 3 . > ': . . tPot I <br /> WWW.WORLDOILCO OM - � <br /> TRANSPORTER EPA # CAI 11 28277036 <br /> r ; , l I It lot' <br /> r , P. I . <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # G TACT NAME ORDER TAKEN BY * HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE TOMER EPA # BILL of LADING/, MANIFEST # <br /> )j <br /> INNER <br /> �.+ ` 'tel' �J �• �:' "_�I � <br /> PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> It too'l <br /> to ...�/w , , <br /> TOTAL <br /> CASH RECD : CHECK # <br /> WASTE DISPOSAL INF MATION <br /> NONIIRCRA HAZARDOUS WASTE, LIQUID (USED OILIMIXED OILS) STATE CODE 2.21 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLU $) STATE CODE <br /> OTHER ) <br /> DESIGNATED TSDF: It % I fill <br /> UNINININI , . ! <br /> ALTERNATE T8DF: ILI <br /> )HUMS P/U :� EMPTY DRUMS ). FACILITY: f3SC <br /> GENERATOR WASTE CERTIFICATION (PLEA iMECK THE APPROPRIATE BOX) <br /> ray eigning below I hereby certify that, <br /> (Waste oil generator/customer MUST check E of the following three boxes) <br /> M ) I have riot mixed any or the waste desorlbed above rw8h any other hazardous waste, the total halide co Ie ;LESS than 1 ,ODO ppm, and the wilate docs not contain any pOBs. 1 have <br /> compiled with the requirements of the applicable Califernlq used ell management regulations to determine ttu Is rue, I agree to accept the additional chargee for the disposal of this wa*te It <br /> the Intormatton I have provide about thio waste 1* incorrect I <br />! i] !+2 I have not mlxad any of the wao2w deacrlbed above with any other haaardoue waste, tho total halide con tr Is GREATER than 1 ,OOD ppm, and the waste does not contain any FGBS, I <br /> have-provided proper documentation to World Ott Environmental Services to rebut the presumption that this Yjas mixed with other hazardous waste, l agree to accept the oddhional <br />€ chargee for the disposal of this waste if the information I have provided about this waste is incorrect i <br /> E <br /> S3) This westm is from a tank which collects waste all from houeehold °dolt-youreelf" (DIY) and/or condRt dxempt *mail quantity generator (CESQG) sources,. To the: best of my <br /> knowledge, the only waste oil contained In my DIY! CPSQG collection tank is soley from DIY and/or GESOG s 11 have not mixed this wastes oil with any other hazardous waste orwaate oil <br /> from other aources. I agree to accept the additional chargovfor disposal of [his waste If the informatlon I hav vkied about this waste is Incorrcet <br /> (All generators/ customers MUS d the following text <br /> I certify that i have s program In piece to reduce the volume and toxicity of waste generated to the degree I ha ermined to be economically practicable and that I have selected the <br /> prectleable method of treatment, storage, or disposal currently available to me which tninimlz a the present a I itu're threat to human liie and the environment <br /> This Individugl signing In the space set forth below on behalf of customer repreaenta and warTanta that heh5bj ft the stnhority to bind customer, that the forgoing deacYptlonta of waste <br /> and materials are true and aoeurate as packaged, marked, and labeled, are ready for transportation in accord with applleeble atate.and Wars) reoOlations, and thatcuetomershall abide <br /> by the Stqndard Terms and Conditiona on the reverse aide of this Service Order. j <br /> Service Orders with an associated hazardous waste rhanifeet (either site zpecik or consolidatsd) are subject i i EPA Fee. The*¢ pose cover the EPA pes�throueh fee and administration <br /> of ithe eManifeet progrgrii7, Theee fees vary tuned on Maniteat type, Applicable tees will appear on your bloll[Al in t Dlqe, , <br /> Customer Signature Date Driver Slgn$turs Date <br /> of <br /> Print Name Print Driver Name <br />