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Feb 0619 , 02 . 48p p , 2 FOR SERVICE CALL, SERVICE ORDER FORM NO . WOES004-B (8118 ) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA 1 -800-727- 2879 SERVICE ORDER N0. FOR ACCOUNTING CALL : �� C� LQ � � � 562-231 - 1550 WORLD ENVIRONMENTAL SERVICES .~ S 7300 CHEVRON WAY, DIXON , CA 95620 r` ' H i 1 -800. 727-2879 P �� P WWW.WORLDOILCOFIRCON9 C ' 6 2019 D TRANSPORTER EPA # CAD028277036 7 , O t 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 QTY UNIT PRICE QTY PIU TOTAL TOTAL CASH REC' Q : CHECK # WASTE DISPOSAL INFORMATION NON- RCRA HAZARDOUS WASTE , LIQUID (USED OIL/MIXED OILS) STATE CODE 221 NON- RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER : DESIGNATED TSDF : ALTERNATE TSDF : DRUMS PIU: EMPTY DRUMS : FACILITY: BSC GENERATOR WASTE CERTIFICATION ( PLEASE CHECK THE APPROPRIATE BOX) By signing below I hereby certify that : (Waste oil generator/customer MUST check ONE of the following three boxes) 0' #i ) I have not mixed any of the waste described above with any other hazardous waste, tholotal halide content is LESS than mco ppm, and the waste does not contain any PC as. 1 have complied wlth the requirements of the applicable California used oil management regulations to determine this is true, I agree fo accept the additional charges for the disposal of this waste if Via informatton I have provided about this waste Is Incorrect [] #21 have not mixed any o1 the waste described above with any other hazardous Mte, the total halide content Is GREATER titan 19000 ppm, and the waste does not contain any PC83. 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 additional charges for the disposal of this waste If the Information I have provided about this waste is incorrect 0 #3) This waste Is from a tank which collects waste all from household "do•it•yourself" (MY) and/or conditionally exempt small quantity generator (CESOG) sources. To the best or my knowledge, the only waste an contained in my DIY/ CESOG collectlon tank Is soley from DIY and/or CESOG sources, I have not mixed this wesle 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 t have a program In place to reduce the volume and toxicity of waste generated to the degree I havedetermined to be economically practicable and that I have selected the practicable method of treabnent, storage, or disposal currently available 10 me which minimizes the present and future threat to human life 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 customer, that the forgoing descriptions of ~caste and materials are true and accurate as packaged, marked, and labeled, are ready for transportation in accordance with applicable slate and federal regulations, and that customer shall abide by the Standard Terms and Conditions on the reverse side of this Service Order, service orders vdth an associated hazardous waste meanest (either site specHie or consolidated) are subject to an EPA Fee. These lees cover the EPA pass-through fee and administration of the efrlanifest program . These lees vary based on Manifest type. Applicable foes will appear on your billing Invoice. 1 r _ Customer Signature Date Driver Signature Date Print Name Print Driver Name