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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-848-727-2879 " <br /> w. <br /> FOR ACCOUNTING CALL: <br /> 582-231-1550 OWORLDOIL f l <br /> ENVIRONMENTAL SERVICES- <br /> 7300 CHEVRON WAY,DIXON,CA 95620 <br /> P <br /> 1-800-727-2879 <br /> WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> T <br /> •11 it .�'� , .{�s.•:t .f' !.. Gli',� " ::'. ...� <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME AKEN 8Y ' HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> V. <br /> PART# DESCRIPTION QTY UNIT PRICE CITY PIU TOTAL <br /> ..=� <br /> 1'4 4= ..'0 I.i i i�f:.:lY.l .i l.. '.I ..'.r`..5'. f{ <br /> 4.6c: . <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED O1L/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER, <br /> u DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> DRUMS PIU: 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 /> V11)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.i have <br /> compiled with the requirements of Ilia applicable California used oil management regulatlons to determine this is/rue,f agree to accept the additional charges for the disposal of this waste It <br /> the Information I have provided about this waste is Incorrect <br /> 0 #2[have not mixed any of tha waste described above with any other hazardous waste,the total halide Content Is GREATER than 1,004 ppm,and the waste does not conialn any PCBs.I <br /> have provided proper documentation to Word Oil EnvlronrgentafrServlces to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional <br /> charges for tha disposal of this waste If the Information I have proWded about this waste la Incorrect <br /> 0 13]This waste is from a tank which collects waste all Tra0 b 'Id"do-It yourself"{DIY}and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil oontalned In my DIY!CE5YiC�. - Is soloy from DIY and/or CESOG sources.I have not m axed this waste oil with any other hazardous waste or waste ell <br /> from other sources.I agree to accept the"clitlonal charge ti I this waste it the Information I have provided about thla waste Is Incorrect <br /> (All generators/customers MUST read the following text s <br /> I certify that 1 havo a program In place to reduce the volume and toxicity of waste generated to the degree t have determfnod tow economically practicable and that t have selected the <br /> precileabie method of treatment,storage,or disposal currently avaliabietome which minimizes the present and future threat to human life and the envlronment. <br /> This Individual signing In the space set forth below on behalf of customer.rep as6nts.and warrants that helshe has the authority to bind customer,that the lorgoing descriptions of waste <br /> and materials are true and accurate as packaged,marked,and Labeled,bre% y:4or transportation in accordance with applicable state and federal regulations,-an that customer shall abide <br /> by the Standard Terms and Conditions an the reverse side of this Service order.. <br /> Service Ordera,wlth an associated hazardous waste manlTaat{either site speciTlc or coaselldaled]am sublect to an EPA Fee.These lees Cover the EPA pass-through fee and administration <br /> of the eManifest program. Theca Tees vary based on Man llfifodf type. Applies}hie Tees will appear on your billing invoke. <br /> ' * Custori 4SIgnature Date Driv&%§Ignature Date <br /> Print Name' Print Driver Name <br />