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rvw5eTTVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DHA <br /> SERVICE ORDER <br /> 1-800-727-2879 NO. <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 582-231-1550 <br /> ENVIRONMENTAL SERVICES•.. <br /> S 7300 CHEVRON WAY DIXON,CA 95620 <br /> H 1-800-727.2879 <br /> 1 <br /> P <br /> P WWW.WORLDOILCORP.COM <br /> D <br /> 0 TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER # ROUTE# TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART # DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH REC'D:_ _ CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> DRUMS P/U: 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 /> 01)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 /> compiled with the requirements of the applicable Califarnia used oil management regulations 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 /> Q !2 1 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 <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 additional <br /> charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect <br /> 0)This waste is from a tank which collects waste all from household 'do-It-yourself"(DIY)anxvor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste obi contained in my DIY!CESQG collection tank is sotey from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste ail <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 incorrect <br /> (All generators/customers MUST read the following text <br /> I eeo tty 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 apace set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgoing descriptions of waste <br /> and matVneiS are true and accurate as packaged.marked.and labeled,are ready for transportation In accordance with applicable state and federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the eManifest program. These lees vary based on Maniiesi type. Applicable fees will appear an your billing Invoice- <br /> , <br /> Customer Signature Date Driver Signature Date <br /> r <br /> Print Name Print Driver Name <br />