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co € c� € SEF C �a� L : i SI 4 i/ ICS C71 aL - FoRr�r nwa . �ruoEsoa4F3 (8i18 ) I & OU.. 727 2_!379 SPF, ) EJRYENVIRONMENTAL ER I L_ O A SERVICE � �7� DIXON C $ $ LFiCLSERVICdE ORDER NON FOR ACCOUNTING CALL � 562 - 231 155aJE $ i . . . sErt , ,�Ir/ � L IR ENVIRONMENTAL. SERVICES .,, s 7300 CHEVRON V ffi(, DIXON . CA 95620 H I 1 - 800 - 727 - 2879 P UllWtN. W0HLD0I € ,CC) RRC0 E TRANSPORTER ETNA '¢ CAD028277036 D T O CUSTOMER TOMER 1 PURCHASE ORDER It ROUTE t1- TRUCK ,jt CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DA71 E ENTERED NEXT SERVICE DATE CUSTOMER FLEA # _ BILL OT LADING] MANiFEST # PART Yl DESCRIPTION OTY UNIT PRICE O` Y P/U TOTAL TOTAL CASH REC ' D: CHECK WASTE DISPOSAL INFORMATION _�� , � NON. RCL A HAZARDOUS WASTE , LIQUID ( USED OIL/MIXED OILS ) SlA6 E CODE 22 i NOWPICRA HAZARDOUS WASTE , LIOUID ( ETHYLENE GLYCOL SOLUTIONS) SATE CODE---- OTHER : CDE_ - OTHEL` : --__..----- --- ----- -- DESIGNATED TSDF : ALTERNATE TSDF : DRUMS EMPTY FACILITY: ESfC. GENERATOR WASTE CERTIFICATION ( PLEASE CHECK K H APPROPRIATE OX) By signing below I hereby certify that : (Waste Cell generator/customer MUSThr eck ONE of the following three boxes ) (j Y1 ) I have not mixed any of the waste described above with any other hazardous waste, the total halide content is. IrSS than 1 ,000 ppm, and the waste does not contain any PCSS , I have compiled with the rectuhements of tine applicable California used oil management regulations to determine tills is true. 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 t2 I have not raised any of the waste described above with any other hazardous waste, the total halide content Is ORLATER than 1 ,000 ppm, arid the waste does not contain any PC €ls. I have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed vilth other hazardous waste, I agree to accept the additional charges for the disposal of tills waste If the information I have provided about this waste Is Incorrect 0 r43) This waste is front 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 my knowledge, the only waste oil contained in my DIY/ CESQG collection tank is soley from DIY and/or CESQG sources . I have not mixed this waste oil with any other hazardous waste or waste oil front 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/ custorn rs MUST read the following text I certify flat I have a program in place to reduce the valuate and toxicity of waste generated to the degree I have determined to be economically 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 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 waste and materials are true and accurate as packaged, marked , and labeled , are ready for transportation In accordance with applicable state and federal regulations, and that customer shall abide by the Standard Terms and Conditions on the reverse side of this Service Order, Service Orders with an associated hazardous waste manifest (efther site specific or consolidated) are subject to an EPA Fee. i h zss fees cover tine EPA pass-through fee and administration of the elianifest program. These fees vary based oil Manifest type. Applicable fees will appear on your billing invoice. Customer SigrratILrre Date Driver Signature Date Print Llrarne Print Driver Name