Laserfiche WebLink
FOR SERVICE CALL.: <br />DIXON OFFICE <br />1-800.727-2879 <br />FOR ACCOUNTING CALL <br />562-231-1550 <br />S <br />H <br />P <br />E <br />D <br />T <br />O <br />ENVIRONMENTAL SERVICESTP, <br />7300 CHEVRON WAY, DIXON, CA 95620 <br />1-800-727-2879 <br />W WW.WORLDOILCORP.COM <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. WOES004-B (8/18) <br />SERVICE ORDER NO. <br />CUSTOMER # <br />GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br />PURCHASE ORDER # <br />R=#TRUCK <br />CONTACT NAME <br />ORDER <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER EPA`: # <br />BILL of LADING/ <br />MANIFEST # <br />PART # <br />DESCRIPTION <br />CITY <br />UNIT PRICE <br />®TY P/U <br />TOTAL <br />TOTAL <br />CASH REC'D: <br />CHECK # <br />NON-RCRA <br />NON-RCRA <br />OTHER: <br />HAZARDOUS WASTE, LIQUID <br />HAZARDOUS WASTE, LIQUID <br />WASTE DISPOSAL INFORMATION <br />(USED OIUMIXED OILS) <br />(ETHYLENE GLYCOL SOLUTIONS) <br />STATE CODE 221 <br />STATE CODE_ <br />DESIGNATED TSDF: <br />- <br />" <br />ALTERNATE TSDF: <br />DRUMS P/U: <br />EMPTY DRUMS: <br />FACILITY: <br />BSC <br />By signing below I hereby certify that: <br />'ra(Waste oil generator/elastomer MUST check ONE of the following three Foxes) <br />I� #1)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 PCEo. I 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 />the information I have provided about this waste is incorrect <br />Q N21 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 <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 <br />additional <br />charges for the disposal of this waste if the information I have provided about this waste is incorrect <br />Q N3) This waste is from a tank which collects waste oil from household "do-it-yourself" (DIY) and/or conditionally exempt small quantity generator (CESQG) sources. To the best of <br />my <br />knowledge, the only waste oil contained in my DIY/ CE54G collection tank is Soley from Oltl 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 [o accept the additional charges for disposal of this waste if the in§ormation I have provided about this waste is incorrect <br />MMECOMMM <br />I certify that I have a program In place to reduce the volume and toxicity of waste generated to <br />the degree i have determined 90 be economically practicable and that I have selected the <br />precticabie method of treatment, srorage, or disposal currently available to me which minimizes the present and future threat io human lite and the environment. <br />This individual signing In the space se¢ packaged. <br />ck below on behalf of customer represents ready <br />for and warrants that he/she has the authority to bind customer, that the forgoing descriptions of waste <br />and materials are true and accurate ns on the rev marked, and labeled, are ready for transportation :n accordance with applicable state and federal regulations, and that customer shall abide <br />by the Standard Terms and Conditions on She 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 eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your Miling invoice. <br />Customer Signature Date Driver Signature Date <br />Print Name Priest Driver Name ._ <br />