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FOB SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA . .�D <br /> SERVICE oI�I�ER No. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 WORLD OIL <br /> ENVIRONMENTAL SERVICES- <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> 1-800-727-2879 <br /> P WWW.WO iLDOILCORP.COM <br /> D <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> QATE REQUIRED DAT-ENTERED NEXT SERVICE-DATE CUSTOMER EPA# SILL of LADING/MANIFEST## <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE COBE 229 <br /> NON-HCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE COBE <br /> OTHER: _ <br /> DESIGNATED TSDF: <br /> ALTERNATE TSCF: <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 genevator/cult rner MUST check ONE of the following three boxes) <br /> N1)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 /> complied with the requirements of the applicab€e California used Or Management regulations to determine this Is true.€agree to accept the additional charges for the disposa$ofthis waste if <br /> the information I have provided about this waste Is incorrect <br /> 0 #21 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 ilia waste does not contain any PCBs.I <br /> 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 <br /> charges for the disposal of this waste it the information I have provided about this waste is incorrern <br /> H 113)This waste is from a tank which collects waste oil from household"do-€t-yourself"(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained In my illy!CESQG collection tank is soley€roan 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 additional charges for disposal of this waste it the information I have provided about this waste Is incorrect <br /> (All generators/customers MUST read the following text <br /> I certify that€have a program in place to reduce the volume and toxicity of was€e generated to Elie degree I have determined to be economically practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal currently available to me which rnlnimizes 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 /> and materials are true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulaifons,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. <br /> 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 fee and administration <br /> of the oManifest program. These fees vary based on Manifest type. Applicable tees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />