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SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8118) <br /> ,ON OFFICE ASBURY ENVIRONMENTAL SERVICES. DBA <br /> -800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WORLD OIL 562-231-1550 <br /> ENVIRONMENTAL SERVICES!. <br /> S7300 CHEVRON WAY. DIXON.CA 95620 <br /> I 1-800-727-2879 <br /> P <br /> P WWW.WORLDOILCORP.COM <br /> E <br /> D 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 /> i <br /> PART# DESCRIPTION QTY UNIT PRICE OTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIVMIXED OILS) STATE CODE 221 <br /> NDN-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: — <br /> DESIGNATED TSDF: _ - <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 /> 6-tl11 have not mixed any of the waste described above with any other hazardous waste.the total halide content Is LESS than f,00a ppm.and the waste does not contain any PCBs I have <br /> complied with The requirements of the applicable Califomla used all management regulations to determine this is true-I agree to accept the additional charges for the disposal of this waste 11 <br /> the Information I have provided about this waste is incorrect <br /> 0 t2 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.1 agree to accept the additional <br /> Charges for the disposal of this waste it the Information I have provided about this waste is incorrect <br /> U t3)This waste is from a tank which collects waste oil from household"do-Tt•yourself"IDM andlor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIY/CESOG collection tank Is coley from DIY and/Of CESGG 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 addlflonal charges for disposal of this waste If the information I have provided about this waste is incorrect <br /> (ATI generators/customers MUST read the following text <br /> 1 certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have deierml tied 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 space set forth below on behalf of customer represents and warrants that heeshe has the authority to bind cualomer,that the forgaing descriplions of waste <br /> and materials are true and accurate as packaged.marked,and labeled.are ready lot transportation In accordance with applicable state and federal regulations,and That custemer shalt 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 loan EPA Fee. These fees caw the EPA pass-Through tee and administration <br /> of the eMani risl program- These fees vary based on Manifest type. Applicable fees will appear on your billing Invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivet'Name <br />