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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-8 (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES. <br /> S 7300 CHEVRON WAY, DIXON.CA 95620 <br /> 1 1-800-727-2879 <br /> P <br /> P WWW.WORLDOILCORP.COM <br /> E <br /> ti TRANSPORTER EPA#CAD028277036 <br /> T <br /> D <br /> CUSTOMER # PURCHASE ORDER # ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 7(.//.-/ t <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: 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 /> THER:DESIGNATEDTSDF: _ --_-- - — — - <br /> ALTERNATE TSDF: <br /> DRUMS PIU: EMPTY DRUMS: _ FACILITY: BSC <br /> 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 /> Q <br /> 81)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 /> complied with the requirements of the applicable Caldomle used all management leguiatlons to determine tills Is true.I agree to accept the additional charges for the disposal of this waste If <br /> the information I have provided about this waste is Incorrect <br /> J I21 have not mixed any of the waste described above with Any other hazardaue Wroter 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 addhional <br /> charges tot the disposal of this waste If the information 1 have provided about thfa waste is incorrect <br /> a 413)This waste Is from a tank which coliacte waste ail from household-do-It-yourself'J01Y)and/or conditionally exempt smag quantity generator(CESOG)sources To the best of my <br /> knowledge,the only waste oil contained In my DIYf CESOG collection tank is sofey from 01Y andlar 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 Ineorect <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 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 spare set forth below on behalf of customer represents <br /> transportation warrants thatIn 0she a the applicable t bindtate s d tofederalr.that the <br /> e forgoing nthat customer oshall abide <br /> f waste <br /> and materials are true and accurate as packaged,marked.and labeled,are ready <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manllesl(either site specdlc or consolidated)are subject to an EPA Fee. These fees cover the EPA peas-through fee and administration <br /> of the eManilust program. These lees vary based on Manifest type- Applicable leas will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name <br /> +— Print Dr ver Name <br />