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FOR SERVICE CALL: SERVICE ORDER FORM NO. WO'ES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1.800-727-2878 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL; WORLD �I L <br /> 562-231-1550 _ <br /> ENVIRONMENTAL SERVICES... <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H 1.600-727-2679 <br /> Q <br /> p WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <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/MANIIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE OTY PIIJ TOTAL. <br /> TOTAL <br /> CASH REC'D: CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE. LIQUID(USED OILIMIXED 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 certlfy Thal: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> #1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is LESS than t,ODD ppm,and the waste does not contain any PCBs.I have <br /> complied with the requirements of the applicable Callfornla 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 t have provided about this wasta i5 IflddrreCI <br /> [] k2 i have not mixed any of the waste described above wilh any ether hazardous waste.the total halide content is GREATER than 1,000 ppm,end the waste does not contain any PCBs.I <br /> have provided proper documentation to World ail Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I 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 #3I This waste is from a tank which collects waste oil from household"do-it-yourself"(D1Y)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste all contained in my D1Y/CESQG collection lank Is soley from DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste oil <br /> From other sources.i agree to accept the additlontil charges for disposal of this waste if the information I have provided about[his waste Is incorrect <br /> (All generators/customers MUST read the following text <br /> €cenify than have a program In place to reduce the volume and toxicity of waste generated to the degree f have determined to be economically practicable and that I have selected the <br /> praclicable 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 authorlly to hind 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 or this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site Spec rill c or consolidated)are subject to an EPA Fee- Theso fees cover the EPA pass-through fee and adminisIratIon <br /> of the eAtanlfest 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 />