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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8118) <br /> I DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER N0. <br /> C FOR ACCOUNTING CALL: WORLD OIL 562-231-155.0 <br /> ENVIRONMENTAL SERVICES-. <br /> 5 7300 CHEVRON WAY, DIXON,CA 95620 <br /> i <br /> 1-800-727.2879 <br /> P <br /> P WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <br /> C CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# HILL of LADING/MANIFEST# <br /> PART# DESCRIPTION OTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION. <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED 01L/MIXED OILS) STATE CODE 221 <br /> NDN-RC'RA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE-- <br /> OTHER: <br /> ODE _OTHER: - - — - <br /> DESIGNATED TSDF: —_� - - – --- - -- -- -- – - – <br /> ALTERNATE TSDF: <br /> DRUMS PIU: EMPTY DRUMS: FACILITY;_ BSC _ <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> ay signing below I hereby cettify that <br /> (Waste oil generator/customer MUST check ONE of the fallowing three loxes) <br /> 0,81)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is LESS than 1,ifoo ppm,and the waste does not contain any PCBs.I have <br /> compiled with the requirements of the applicable California used oil management regulations to determine this is true I agree to accept the additional charges for the disposal at this waste 11 <br /> the Informatian 1 have provided about this waste Is Incorrect <br /> 1] $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 011 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 II the Information I have provided about this waste Is incorrect <br /> 0 93)This waste Is from a tank which collects waste oil from household '(Jo-i4yourse11"IDIY)and/or conditionally exempt small:quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste ail contained In my DIY/CESOG coilectlon tank Is Soley from DIY andlor CESOG sources.I have not mixed this waste all with any other hazardous waste or waste oil <br /> from other sources.I agree to accept the additional charges lot disposal of this waste It 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 to place to reduce the volume and toxicity of waste generated to the degree 1 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 space set forth below an behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials 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 Canditions on the reverse side of this Service Order. d <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. Th lees cover the EPA pass-through fee and administration <br /> of the eManifest program. These fees very based on Manifest type. Ar)plicabie fees will appear an your bliling Invoice. <br /> � 7 <br /> Customer Signature /�te ver Signatur Date <br /> -�� j L_ L' <br /> Print Name Print Drivel ame <br />