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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8118) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. 1-800-727-2879 FOR 562-231-1550 NTING CALL. WORLD OIL ENVIRONMENTAL SERVICES,. sf 7300 CHEVRON WAY,DIXON,CA 95620 H I 1.800-727-2679 P P WWW.WORLDOILCORP.COM E TRANSPORTER EPA#CAD028277036 T 0 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 OTY UNIT PRICE QTY P/U TOTAL fLu t-10 �. C 5 . TOTAL CASH REC'D: CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE., OTHER:- DESIGNATED THER DESIGNATED TSDF " 1 rg,ijli F4i'7I 14 CI -I-A 1., 1 Iif- ; a•!hit .R. - •.Ai 04 ALTERNATE TSDF: L .6111 .rut-fir -in i;ywl DRUMS P/U: EMPTY DRUMS:_ FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) By signing below 1 hereby certify that (Waste oil generator/customer MUST check ONE of the following three boxes) I i 41I 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 waste does not contain any PCBs I 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 disposal of this waste It the Information I have provided about this waste Is incorrect 11 921 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 addlelonal charges for the disposal of this waste It the Information I have provided about this waste Is incorrect F! 03)This waste Is from a lank which collects waste oil from household"do-it-yourself"(DIY)and/or conditionally exempt small quantity generator(CESOG)sources To the best of my knowledge,the only waste oil contained In my DIY/CESOG collection tank Is seley from DiY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil from other sources.I 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 that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economice'ly practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human lite and the environment. This Individual signing In the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind austomar,that the forge-ng descript.ons of waste and materials are true and accurate as packaged,marked,and labeled,are ready for transportation In accordance with applicable state and faderai regulations,and that customer shall aa-da by the Standard Terms and Conditions on the reverse side of this Service Order. Service Orders with err associated hazardous waste manifest(ehher aIle specific or consolidated)are subject to an EPA Fee. These fees cava[ehe FPA pasa.lhrough fee and adminlstral.on of the aManifest program. Theseleasvary based on Manifest type. Applicable fees will appear on your billing invoice. Customer Signature Date / Driver Signature ti Date Print Name T Print brivew am