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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B (8/18) <br /> DIXON 6FFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: N3297'50 <br /> 562-231-1550 �� 0 L <br /> ENVIRONMENTAL SERVICES, <br /> S7300 CHEVRON WAY,DIXON,CA 95620 <br /> I 101DAS-,TRACY RACY 1-800-727-2879 <br /> P 2615W GRANT L INE RD WWW,WdRLDdILCORP.COM . 27615W GRANT LINE RD <br /> E TRANSPORTER EPA#CAD028277036 <br /> 'T TRACY. i,-`A 95304 <br /> - TRACY, CA 95304 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT <br /> , NyAME ORDER <br /> 'TAKEN BY HALIDES <br /> llfllu�s4L C= _&I Jr L�lE' 1rSAM., I l <br /> DATE REQUIRED DATE ENTERED NEXT! DA41—E CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 7f�)11C0 0 Chi LO00440 68 )2 <br /> PART# DESCRIPTION OTY UNIT PRICE QTY PIIJ TOTAL <br /> GM USED METAL 04AND GHSOLlNE FILTERS ? $55,00 $110.00 <br /> QFDR di Fli.i ER DRUM REPLAGEM ENT- NO CHARGE 2 $0.00 $0.00 <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> HON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL MIXED OILS) STATE CODE 221 <br /> HON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODS <br /> OTHER: ,.i tii ':�rsan :sr-YAan,^ rciarnc- r in rcil rear Inrhie�^PF i c--Ar=ntizc--s'l <br /> DESIGNATED TSDF: 1 Cu iyiAirACSEitiiEN s fi�C.Tfi�GG U5 HIG�IINR`r 6°. _fLifvrA.At' <br /> ALTERNA DF: <br /> C'-nr• 5 uP - A=urs!irbnaaer:Sam Read <br /> DRUMS PIU: EMPTY DRUMS: FACILITY: eSG <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below!hereby certify that, <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑#1)I have not mixed any of the waste described above wlth any other hazardous wasie,thb total halide content Is LESS than 1,099 ppm,and the waste does not centaln any Peas-I have <br /> compiled with the requirements of the applicable Callfomla used oil management regulations to determinethis is true.I agree to accept the additional charges for the dlsposai of Ihls waste II <br /> the information I have provided about this waste Is Incorrect <br /> 0112 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.nof contain any PCBs.I <br /> have provided proper documental[nit to World 011 Environmental Seryices to rebut t b a presurn ptian that thIa waste was mixed with other hazardaus waste.I agree I accept the additional <br /> charges for the dlsposaI of this waste If the Information I have provided about this waste Is Incorrect <br /> 0 63)This waste Is from a tank which collects waste all from household"do-It-yoursall"(DIV)andlor conditionally exempt small quamlty generator(CESOG)sources.To the best of my <br /> knowledge,the only waste all contained In my DIY!CESOG collection tank Is soley from 01Y andlor CESLIG sources.I have not mlxod thla waste oil with any other hazardous waste or waste 011 <br /> from Other sources,I agree to accept the additional charges for disposal of this waste If the Information 1 have provided about this wasto 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 economl ca lly practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal currently avail an le to roe which mi nimlzea the present and ful Lire threat to human the and the environment. <br /> This Individual signing in the space set forth below on behalf of customer represents and warrants that helsrte has the authority to bind customer,that the forgain9 descriptions of waste <br /> and materials are true and accurate as packaged,marked,and labeled,are read y for transpottatlon In accordance with applicable state and federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions an the reverse side of this Seryice Order. <br /> Service Orders with an associated nazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee.T fees cover the EPA pass-through fee and administration <br /> Of the Man Itest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> 0I� i <br /> Cus❑mer Signature Date D ' r Signature Date <br /> � 44. <br /> Z,-0 ail f <br /> s <br /> Print Name J Print Driver Name <br />