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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. 1-800-727.2879 FOR ACCOUNTING CALL: ��562-231-1550 (,,,, ,WORLD ENVIRONMENTAL SERVICESTM S 7300 CHEVRON WAY,DIXON,CA 95620 H 1-800-727-2879 I API'ONi(�.! (��( f�hl�iE= LLC LA i I !i�CF� h1!V T ONiF�I >vNTLF�PfISS LLC-;� P P7011 (.i`r RCY P;,/;,rV`( WWW.WORLDOILCORRCOM LBOX jk u3 E TRANSPORTER EPA#CAD028277036 T LA IJ R.OP, CA 953:0 ST OC"t i UN, CA 95215 (1109) 903-8695 (209) rQJ" r 4 ' 4 900 CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES ANT608 CER-,5-6 `1 O!-4N/SAM READ sniartine DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# 1OM1/2019CAU30 3&5703 C( 7< v sW` J PART# DESCRIPTION QTY UNIT PRiCE QTY P/U TOTAL S5.O�(t 53 GbILL014 O/T DIRI,MI (RiECONDITIONrC)) 1 CAPER FILTPaS; PEF DRUM 1 ^IVIS EiV,AN1; ST EPA FEE&ADMiIq SI T` SREC!FIC. MAN"FES 1 aCWN?o].�l.s6-a-rr BAT;H _ TOTAL CASH RECD: CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATED TSDF: ALTERNATE TSDF: DRUMS P/U: EMPTY DRUMS: __— FACILITY: AVED GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPRO"RIAT9f4T0q_By signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following , Q #1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is LESS than moo ppm,and the waste does not contain any PCBs.I have 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 the Information I have provided about this waste Is Incorrect Q #21 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 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 Q #3)This waste Is from a tank which collects waste oil from household"do-It-yourself"(DIV)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my knowledge,the only waste oil contained In my DIY/CESOG 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 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 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 practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human[Ile and the environment. Thlo individual signing in the space set forth ha[aw on behalf a1 customer represents and warrants that hetshe has the aulttnrity to For,thnl the forgoing desorlptions of waste and materials are true and accurate as packaged,marked,and Iabaled,lire ready for transportation In accordance with applicable state.an a eral regulations,and that customer shall abide by tlfe Slnndard Terms and Conditions on the rouerse slde of lhiR Sstrvlce Order. Service Orders wit -aasnelatad hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These f e ov the EPA pass-through fee and administration of the eManitas o ram. These lees vary based on Manifest type. Applicable fees will appear on your billing invoice. mer Signature Date/ Driver S gn re 'DWe/ rinl I�me Print nri+rar Name -