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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879. SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: N3237225 <br /> 562-231-1550 Gwor&D.01L <br /> ENVIRONMENTAL SERVICES. <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H ANTONIN II ENTERPRISES LLC- LA f}-ROS' <br /> I 1-800=727 2879 AN"C'OiViNI EN i'ERPRISES L.!-C:-ANT <br /> P ;rr!•i f)BAR CSF r'IC1lVY ' O BOX W?6 <br /> W W W.WORLDOI CCORP.COM <br /> oTRANSPORTER EPA#CAD028277036 <br /> T i.A I Hi OP,CA 95330 Sl OC K ON, CA 95215 <br /> 0 - (20a) 993-8695 (209) 466-*00 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ANIT008 i: .CU T E '12` + JOHN SCHEDULED-1 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 3111120210 55/2020 CAL000385703 ` -16 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> Vv0SC, USED OIL SERVICE CHARGE 1 <br /> V'V0 USEC OIL/MIXElO OILS 2.10 -25.0 <br /> JOHN_2'C e-465-,4SGG E ATCI ' <br /> TOTAL <br /> CASH REC'D: CHECK# T <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: ASBURYFNVIRONMENTAl.SEWicr -CEPiES. 1920 NIORGAN ZED.-C 75. CN[100 3 3"a30 <br /> ALTERNATE TSDF: <br /> Accaua!Aw ter:Sam Rr- <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIAT 130 <br /> By s igning below I hereby certify that: , <br /> (Waste oil generator/customer MUST check ONE of the following three b xes) <br /> #t)1 have not mixed eny of ata wasto described above with any other hazardous waste,the total hallde content Is LESS than 1,000 ppm,and the waste does not aiat��elt�any?�BS.'I.have^" <br /> compiled with the requirements of the applicable Calltorrrin used oil management regulations to determine this Is true.l agree to accept the additional charges for.tFie dispnsAl'of thin waste If <br /> the Information I have provided about this waste Is Incorrect <br /> ❑#21 have not mixed any of the waste described above with any other hazardous waste,the total hallde content is GREATER then 1,000 ppm,and the wasto does not contain anySPCps,I <br /> have provided proper documentation to World Oil Environmental Senrlces to rebut the presumpllon that this waste was mixed with other hazardous waste.I agree to accept the addttiottsl;', <br /> charges for the disposal of this waste If the Information'I have provided about this waste Is Incorrect + ' <br /> :•.�4 <br /> 0#3)This waste Is from a tank which collects waste all from household"do-It-yourself"(DIY)ancvDr conditionally exempt small quantity generator(CESOG)sources,To the past of my + ' <br /> knowledge,the only waste oil conlalned in my DIY/CE9011 collection tank Is Soley from DIY and/or CESQG sources,l have not mixed this waste oil vMh any other frazardous 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 Ilrls waste Is incorrect <br /> (Al I'generators/customers MUST read the following text <br /> 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 cconomlcally practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal currently available to me which minimizes the present and luture threat to human life and the environment. <br /> This Indlvldual signing In the space set forth below on bahalf of customer represents and•warrants that helshe has the authority to bind customer,that the forgoing descriptions of wanto <br /> and materlals are true and accurate aspackaged,merkod,and labeled,are ready for transportation in accordance with applicable state and Federal regufatlons,and]list customer shall abide <br /> by the Standard Torms and Conditions on/fie reverse side of this Servile Ordcr. <br /> J <br /> Service Or with Rn associated hazardous waste manifest(either site apecllic or consolidated)are subject to an EPA Fee.These fees cover the EPA pass-through fee and administration <br /> of the e t feat program. Than fees vary based on Manifest type. Applicable fees will appear on your hflling invoice. <br /> usto r Signature Daterlve`IS r Sure Date <br /> Or <br /> Print ame `� Print Driver Name <br />