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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA FERVI,�C�IEORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: ` i <br /> 562-231-1550 'WO R L D O I L <br /> ENVIRONMENTAL SERVICES. <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> " ANTONNI ENTERPRISES LLG- LAI iiROP 1-800-727-2879 ANTONINI ENTERPRISES LLC-ANT <br /> P 70.1 D,AR Y P110P rr WWW.WORLDOILCORP.COM FPO BOX 8463 <br /> E _ TRANSPORTER EPA#CAD028277036 <br /> T LitI HROP,CA 05530 STOC=KTOIN, CA,95215 <br /> ;209) sS6-3595 (20�) 460-4900 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ANTeOu f.CUTE 12, JOHN SCHEIDUL_ED-I <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 5117/2020 83/12/'2020 CAL000385703 <br /> PART# DESCRIPTION QTY UNIT PRICE OTY P/U TOTAL <br /> WOSC ; SED 0IS�ELRviC=— G <br /> = -PCE <br /> UtflI. :-. SII./ ViXEU OI_ <br /> :!00 5 <br /> TOTAL <br /> CASH REC'D' CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF:_ m.wr�l lFd1'��Ut�ln1«n�,:�,urni sr-Ixuir r;.CFtE }x^n n11,��>arf f, 13 r � .r, ,3rf1 l^na��z _ a ti r�I nr,ljci 8D <br /> ALTERNATE TSDF: <br /> =7unt Manane,:S-rn RNad <br /> DRUMS.P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> Sy sr ng bora"I hwoby certify tool: <br /> (Waste oil generatorlcustomer MUST check ONE of the following three boxes) <br /> NT)I have not mixed any of the waste described above with any othor hazardous waste,the total hallde content Is LESS than 1,000 ppm,and the wnate does nol conlaln any PCBs,1 have <br /> compiled with the requirements of the applicable California used oil management regulations to determine this Is true.I agree to accept the addltlonal charges for the disposal of this waste If <br /> the Information I have provided about this waste Is Incorrect <br /> ❑fix l have not mixed any of the wasto descrlbod above with any oihor hazardous waste,the 1013E heflde content Is GREATER than 1,000 ppm,and the waste does not conlaln any PCBs.I <br /> have provided properdocumunWion t0 world oil Environmental Services to rebut the presumptlon That this waste was mixed with other hazardous waste.I'agree to accept the addltlonal <br /> charges for the disposal of thls waste If the Information I have provided about this waste Is incorrect <br /> ❑ <br /> 93)This waste Is from a tank which collects waste oil from household"do-it-yourself"(DIY)sndlor conditionally exempt small grandly generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIY/CESQG collection lank Is soloy from DIY andlor 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 /> (All 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 I have determined to be oconomioally 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 behall of customer represents and warrants that ho/she has the authority to bind customer,that the forgoing descrlptlons of waste <br /> and materials ars true and accurate as packagod,narked,and labeled,are ready for transportation In accordance with applicable stale end federal regulations,end trtat customer shall abide <br /> by rho Standard Toms and Condltlons on the reverse side of this Service Order. <br /> Seryice Orders h an associated hazardous waste manilost(either site specific or consolldated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of thesfA st'progrom. These I bar Lod on MAnlfesl type. Applicable fees will appear on your b)lTing Invoice. <br /> Cus er bignature Date Driver Signature Date <br /> Print Name Print Driver Name <br />