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OR SERVICE CALL: <br />DIXON OFFICE <br />1-800-727-2879 <br />FOR ACCOUNTING CALL: <br />562-231-1550 <br />H Lf�:1/tl C35i7i` k Oii_ i iC — L.,�tu`u i <br />1 1 X1843 13 HARLAi•'! Rr.) <br />P <br />F ENICH CAMP, CA 95231 <br />T u 98331 <br />ORDERSERVICE <br />ENVIf20NMENTAL SERVICES'm <br />7300 CHEVRON WAY, DIXON, CA 95620 <br />1-800-727-2879 <br />,S*0 1 <br />FORM NO. WOES004-8 (8/18) <br />SERVICE ORDER NO. <br />2961451 <br />D <br />Od� 91 211 2019 <br />13 P1899 <br />F SNO, CA 934722 <br />CUS�OME # <br />GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY <br />l have not mixed this <br />HALIDES <br />from other sources. <br />I agree <br />to accept the additional charges for disposal of this waste If the information I have provided about this waste is incorrect <br />+'1 <br />+"+.i i mpl I LI I Iuz, <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER EPA # <br />BILL of LADING/ MANNIFE(ST`# <br />,t/ i <br />CAMU1JUZ0_0_T44W <br />o�as V <br />PA5.../ <br />, <br />QTY <br />UNIT PRIQE <br />QTY P/U <br />TOTALr <br />t-, I •J\ <br />_ ./'u1 LSV r f_::r 1 3 <br />7 <br />.l t_s.t�V <br />i' nr-1 <br />_7PJOHE <br />fF4 - ,J u 4,•Ii4,�..,, a.v r r1'-4_,11rte.6 <br />.t <br />,T- <br />.�/ <br />—Q• � - <br />EMS <br />EmANiFE CTC EPA FE= 8, <br />ADMIN SI TEN SPECIFIC <br />MANIFES <br />1 <br />$10000 <br />$10,00 <br />i- RSR! 11Ai <br />.l&P I BRIAN ;:El.l, 4; 20ge 56 4-llO005 <br />BATCH <br />TOTAL <br />CASH REC'D: CHECK #. <br />WASTE DISPOSAL <br />INFORMATION <br />NON=RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) <br />STATE CODE 221 <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) <br />STATE CODE <br />OTHER: <br />DESIGNATED TSDF: <br />ALTEgNAi T QF: <br />C - <br />`, <br />t. i <br />6 rS �zs <br />BSC <br />DRUMS P/U: EMPTY DRUMS <br />(/ FACILITY: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />Q #1) I have not mixed any of the waste described above with any other hazardous waste, the total halide content is LESS than 9,000 ppm, and the waste does not contain any PCBs.1 have <br />complied 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 if <br />L <br />the information I have provided about this waste is incorrect <br />Q #21 have-not <br />mixed any of the waste described above with any other hazardous waste, the total halide content is GREATER than 9,000 ppm, and the 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 if the information I have provided about this waste is incorrect <br />Q #3) This waste is from a tank which collects waste oil from household "do-it-yourself" (DIY) and/or conditionally exempt small quantity generator (CESOG) sources. To the best of my <br />knowledge, the only waste oil contained in my DIY/ CESOG collection tank is Soley, from DIY and/or CESOG sources, <br />(All generators/ customers MIDST Dead the following `text <br />1 certify that 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 <br />practicable 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 authority to <br />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 s regulations, 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. They <br />of the eManifea ^r^^rem. These fees vary based on Manifest type, Applicable fees will appear on your billing invoice. <br />mer Signature <br />Date <br />CJCl <br />the EPA pass-through fee and administration <br />Date <br />l have not mixed this <br />waste oil with any other hazardous waste or waste oil <br />from other sources. <br />I agree <br />to accept the additional charges for disposal of this waste If the information I have provided about this waste is incorrect <br />(All generators/ customers MIDST Dead the following `text <br />1 certify that 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 <br />practicable 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 authority to <br />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 s regulations, 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. They <br />of the eManifea ^r^^rem. These fees vary based on Manifest type, Applicable fees will appear on your billing invoice. <br />mer Signature <br />Date <br />CJCl <br />the EPA pass-through fee and administration <br />Date <br />