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FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004-13 (8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , IBA SERVICE ORDER NO. <br /> 1 -800-727-2879 <br /> FOR ACCOUNTING CALL : <br /> 562-231 - 1550 WORLD OOL <br /> ENVIRONMENTAL SERVICESn.. <br /> S 7300 CHEVRON WAY, DIXON , CA 95620 <br /> 1 -800-727-2879 <br /> P <br /> E WWW. WORLDOILCORRCOM <br /> D TRANSPORTER EPA # CAD028277036 <br /> T <br /> O <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # <br /> 1 <br /> PANT # DESCRIPTION QTY UNIT PENCE QTY P/U TOTAL <br /> t , <br /> .TOTAL <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER : <br /> DESIGNATED TSDF : <br /> ALTERNATE TSOF : <br /> DRUMS P/U EMPTY DRUMS : FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION ( PLEASE CHECK TIDE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer € UST check ONE of the following three Foxes) <br /> D 31 ) 1 have not mixed any of the waste described above vlth any other hazardous waste, the total halide content is LESS than 1 ,000 ppm, and the waste does not contain any PCBs. I have <br /> complied with the requirements of the applicable California used oil management regulations to determine this is true. l agree to accept the additional charges for the disposal of this waste it <br /> the information i have provided about this waste Is incorrect <br /> Q «2 1 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 additional <br /> charges for the disposal of this waste if the Information I have provided about this waste is incorrect <br /> Q A3) This waste is from a tank which collects waste all from household "do•lt•yourseit" (DIY) and/or conditionally exempt small quantity generator (CESQG) sources. To the best of my <br /> 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 <br /> from other sources. I agree to accept the additional charges for disposal of this waste if the information 1 have provided about this waste is Incorrect <br /> (Ali generators/ customers !MUST read the following text <br /> I certify that I have a program in piece to reduce the volume and toxicity of waste generated to the degree I 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 bind customer, 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 state and federal 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. 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 billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />