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FOR SERVICE CAk 0 <br /> SERVICE ORDER FORM N0.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE OfIDER NO. <br /> FOR ACCOUNTING CALL: WORLD <br /> ���D ^�� <br /> 562-231-1550 O„/ <br /> ENVIRONMENTAL. SERVI(F. <br /> 7300 CHEVRON WAY,DIXON,CA 95620 <br /> 1-800-727.2879 <br /> E WWW.WORI_DOILCORP.COAA <br /> DTRANSPORTER EPA H CAD029277016 <br /> Q) 441-L3�r .�1', / 72 <br /> jCIJSTOMER# j PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> S C"63-6 1 TOUTE °2/ qoo <br /> I .JA AF) -,)'f <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> uA.L000145%,,-'.6J �� X5,2 IGI�}JJIC <br /> PART# DESCRIPTION QTY UNIT PRICE OTY P!U TOTAL <br /> .lSED, 014 `�q1 j t r _ /�Jr ✓r _ _ -' <br /> VVQ J,S-D OII_1 %41X1-:D 00-1; - "-23 _ <br /> Sc�ViCE ASAP. 7`I-EASE CAL_'vW ETA ASAP, <br /> rL f T6TAL <br /> rMS <br /> D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> RA HAZARDOUS WASTE, LIQUID (USED OIUMIXED OILS) STATE CODE 221 <br /> RA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> ATED TSDF: i i 1 t,` F,r _ n ^-RGc ^j cmc❑,,^ .,,� - <br /> ATE TSDF: <br /> EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> sy s Hing below I hereby certffy that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> tt I 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 PCes.I have <br /> complied with the requirements of the applicable Callfomia used all management regulations to determine this Is true.I agree to accept the additional charges for the dlaposal at this waste 0 <br /> the information I have provided about this waste is incorrect <br /> 1142 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.t <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 a"miot the additional <br /> charges for the disposal of this waste If the information 1 have provided about this waste Is Incorrect <br /> U x3)This waste is from a tank which collects waste oil from household"do-It-yourself'(DIY)and/or conditionally exempt small quantity genaratur(CESQG)source&To the beat at my <br /> knowledge,the only waste oil contained in my DIV!CESOG collection tank Is soley from DIY andlor CESOG sources.1 have not mlxed this waste oil with any other harardous 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 /> 1 certify that I have a program in place to reduce the volume and toxicity at waste generated to the degree I have determined to be uvunundeully practicable and that I cavo selected the <br /> practicable method of treatment,storage,or dispoasi currently available to me which minimizes the pre*eni and future Ihreal to human life and the environment. <br /> This individual signing In the space set forth below on behalf of customer repre*enta and warrant*that he/aha hay the authority to Mid cuawutur,that the forgoing dsseripllons of wets <br /> and materials are true and accurate as packaged,marked,and labeled,are ready for tranapol latlon In accordance with applicable,tato and luderol rugulallona,and lhsl customer shall abide <br /> by the Standard Term&and Conditions on the reveme side of thi*Service Ordur. <br /> s*rvlrx Orders wllh an a*sociated hazardous waulo maul lout(either situ*Iwclllu of t:onrolldalnd)ate oub)a,.t to.tu t:PA Fen. 1 ties cuvur the EPA yes*-Ihruuyh lav and rdmurls lratloa <br /> o1 the eManifest progr These feel,vary balked an Manifest type. Applicable fees will appear on your trilling irtvoi, <br /> XCustomer attire Date fivy�Stg attire Date <br /> Print Name Print Driver Name �� <br />