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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 562-231-1550 ' <br /> ENVIRONMENTAL SERVICES <br /> - <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> " �,:); , r ' 1-800 727-2879 HAZARUOU�U16P,,;.:zIiL SNrCIr,�;. <br /> P WWW.WORLDOILCORP.COM PG[3QX`513 <br /> D TRANSPORTER EPA#CAD028277036 <br /> TRUCKEE, CA ilii t 60 <br /> T <br /> 0 :530)557-3000 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES • <br /> CFR 1 I kc0siG <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 102 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> Aft(11'.4 ittafl::! :f�Tr1?IGF! j <br /> MAI tIFL-:f r PE.. <br /> E=MPTY[)f%IUNI F:ISrJCSAL %1ETAL 55G 1 ,✓ <br /> i 55 GAI_LO[I Cl!_1 DRUN'I (RECONDITIONED) ! <br /> TOTAL <br /> CASH REC'D: CHECK <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER:—_ -- <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: _.- - - - -- -- — <br /> DRUMS P/U: EMPTY DRUMS: FACILITY:_ BSC__ <br /> GENERATOR <br /> SC _GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 #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 PCBs.I have <br /> compiled 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 it <br /> the information 1 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 /> 0 #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.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 I have provided about this waste is incorrect <br /> (All generators/customers MUST read 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 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 /> r:uni+to�wereSignature <br /> i nature Date - riv r Signaturenature Date <br /> rin+ me <br />