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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8118) <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 /> H <br /> I 1-800-727-2879 <br /> WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA #CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA 4 BILL of LADING/MANIFEST N <br /> PART # DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NDN-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 PIU: EMPTY DRUMS: FACILITY. BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby carlity that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> J a1)I have not mixed any Of the waste described above with tiny 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 California used oil management regulations to determine this 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 mcorreet <br /> J 421 have not mixed any of the waste described above with any other hazardous waste.the totat halide content Is GREATER than 1,000 ppm.and the waste does not contain any PC89-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 addillonal <br /> charges For the disposal of this waste d the Information I have provided about this waste is Incorrect <br /> -.I v3)This waste Is from a lank which collects waste oil from household"do-it-yourself"(DIY)andlor conditionally exempt small quantity generator ZCESOG)sources.To the best of my <br /> knowledge.the only waste Oil contained in my DIY!CESOG collection tank Is soley from DIV andlor 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 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 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 behatl of customer represents and warrants that helshe 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 Conditions on the reverse side of this Service Order. <br /> Service Orders With an associated hazardous waste manifest(either site spuelfic or consolidated)are subject t0 so EPA Fee These fees cover the EPA pass-through fee and administration <br /> of the eMenlfest program These tees vary based on Manifest type. Applicable tees wilt appenr on your billing invoice- <br /> _ <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br /> I <br />