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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B (8/18) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA 1-800-727-2879 SERVICE ORDER NO. FOR ACCOUNTING CALL: �D�L� �� 562-231-1550 ENVIRONMENTAL SERVICESTM s 7300 CHEVRON WAY, DIXON,CA 95620 H 1 l`J ;:J(`'ii�l EI`J +LL r�'ct== I r ��, s 1-800-727-2679 r_ car cJl ) P _ _. ., �_ ., Lam.- �AiI- r:0 AN(Ci�1IN1r.._NT _R.PR _L.0 -rinrI E 701 11—„Ai�1C''!PK1P,!Y WWW.WORLDOILCORRCOM CQ ,SOX 84613 D TRANSPORTER EPA#CAD028277036 T L12,-,HF.'C)R,CA,OS„3n S'f'C)Ci�(UN, CFS -,'5 2 (2,09) CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES AN IF,30r8 ICJ IT}= I tA& C li r DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# -11C•/732L 1 /120 19 C �LOOn�8;>7G3 �1e) PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL tf�,r ) r --------•-- TOTAL CASH REC'D: 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: tom7VAA :•:� ate: r �. s'1p�� = - @J DRUMS P/U: EMPTY DRUMS: FACILITY: BSC .hil�t,/ 11 n GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE-BOX) Ely Mgning below I hereby certify that: (Waste oll generator/customer MUST check ONE of the following three boxes) V/,,),have not mixed anyof the waste described above with any other hazardous waste,the total hallde conivill Is LESS than 1,000 ppm,and the waste does not contain any PCes.I have compiled with the requirements of the applicable California used oil management regulations to deiermine this is true.I agree to accept the addillonal charges for the disposal of this waste It 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 0)This waste Is from a lank which collects waste oil from household"do-It-yoursell”(DIY)anchor conditionally exempt small quantity generalor(CESGG)saurees.To the best of my knowledge,the only waste oil contained In my PNI CESQG collecllan tank Is soley Irony DIY andlor C E:RM sources.I have not mixed this waste oil with any other hazardous waste or waste olI 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 1 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 Indivlduelsigning in lite spare set forth below on behalf of customer represents and warranta that helshe has the authority to bind euatdmor,HIM the forgoing descriptions of waste and materials are huo and accurate as packaged,marked,and lahelad,are ready for transportalion In accordance with applicable stale and Iederal regulations,and that customer shall abide by(lie Standard Teri ns and Cortd[flons on the reverse slde of IhIs$erviee'Ord or. Service Orders W lfbn ass "fated haznrdou;wnsfi manifest(elthor site specific or consolldaled)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration of the ohtanlfesi rdgr These leas vary hosed on Manifest type. Applicable fees will appear an your billing Invoice. Customer ffignatur Date D&erlIgnature Date Print NamA Print Driver Name