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FOR SERVICE CALL : SERVICE ORDER FORM NO , WOES004- B (8/18 ) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA 800-727- 2879 SERVICE ORDER NO. FOR ACCOUNTING CALL: 562 WORLD OIL-231 - 1550 ENVIRONMENTAL SERVICES ,, s 7300 CHEVRON WAY, DIXON , CA 95620 I 1 -800 -727-2879 : l " P WWW.WORLDOILCORRCOM E TRANSPORTER EPA # CAD028277036 T °ENVIRONMENTAL HEALTH DFPARTMENT CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # / BILL of LADING/ MANIFEST # PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL [Fri Lo vL :1 TOTAL CASH REC ' D : CHECK # WASTE DISPOSAL INFORMATION NON -RCRA HAZARDOUS WASTE , LIQUID ( USED OIL/MIXED OILS) STATE CODE 221 NON -RCRA HAZARDOUS WASTE, LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER : DESIGNATED TSDF : ALTERNATE TSDF : DRUMS PIU : EMPTY DRUMS : FACILITY: BSC GENERATOR WASTE CERTIFICATION ( PLEASE CHECK THE APPROPRIATE BOX) By signing below f hereby certify that: � . (Waste oil generator/customer MUST check ONE of the following three boxes ) I;] ir1 ► I 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 wastedoes not contain any PCBs. 1 have 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 dlepoeal of chis waste If the Information I have provided about this waste Is Incorrect Q #2 f 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 Q ar3) Thls waste Is from a lank which collects waste oil from household '•do• lt-yourself' ( 131Y) andlor condlltonally exempt small quantity generator (CESQG) sources, ro the best of my knowledge, the only waste all contained in my DIY! CESQG collection tank Is Soley from MY andlor CESQG sources, t have not mixed this waste oil with any other hazardous waste or waste oil tram other sources . l agree to accept the additional charges for disposal of this waste If the information I have provided about this waste Is Incorrect (All generators/ customers MUST read the following text I certify thst I have a program In place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically practicable and that I have selected the practicable method of treatment storage, or disposal currently avallable to me which minimizes the present and future threat to human life and the environment. Thls Individual signing in the spacesel forth below on behalf of customer represents and warrants that heishe has the authority to bind customer, that the forgaing 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 by the Standard Terms and Conditions on the reverse side of this Service Order. 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 feeand administration of the eManlfest program . These fees vary based on Manifest type, Applicable fees will appear on your bl ling Invoice, d4 d 6 did Customer Signature Date Driver Signature Date Jy f Print Name Print Driver Name V E60Z6b660Z }sa} d69 ; Z6 ' 66LZaeIN