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FOR SERVICE CALL: SERVICE ORDER FORM NO, WOE8004•S (8/18)
<br /> DIXON OF%E ASSUPY kNVIRq ENTAL ..ERVIC E Sr DBA SERVI E�1 R NO,
<br /> 1 �>IW727-2879 ., e `., t , • ,da'.,i y
<br /> FOR ACCOUNTING CALL: w LCO � � a
<br /> 582-231 -1550 It f
<br /> ENVIRONMENTAL SERVICESm
<br /> H INTERNAI 101' IAL l,r^d t »(} 1� 1:! "t ;,t) 9300 CHEV14ON WAV, DIXON, CA 95820
<br /> d t�:> . 1.cac:t t r.7ract t -800d,727,2079 4l , . ' f ! ,( : i "�cr; I: {:71 (. .? ,�; I 1 ),; : ,
<br /> PWWW.WORLDOILCORP.COM
<br /> E TRANSPORTER PA # CA0028277030
<br /> ° L.OUI . CLL t;(;; 2A.0 � l.;'SI.)I , s, 'P'' 6N t,
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<br /> ('2109 ) 'f2 rpt: 1 ; r ,sl) ry 'r
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<br /> CUSTOMER If PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES
<br /> ,, cxut5
<br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE . CUSTOMER EPA # BILL. O LADING] MANIFEST #
<br /> PART # DESCRIPTION OTY UNIT PRICE QTYP TOTAL
<br /> " ;:1. h- 7 . 4 al_ `:1 I L . ;% _'n ;.i. l ) ,) / 1 ; ' ; 1 l,'1t.: .,
<br /> C�FI�I !.")IL. 17ILT (-m tR 1)1� UNI �a1; f 'yl.�� C: 6 .: ME:. WT NO C.I�,� la (� 1�_ (
<br /> PLPAI'l CALI PROIN" " 109-;!ePic6 .i670 P; 'Yt :'td It µ
<br /> TOTAL
<br /> CASH REC'D:_ _ CHECK #
<br /> ANN WASTE DISPOSAL INFORMATION
<br /> WAII NON*RCRA HAZARDOUS WASTE, LIQUID (USED OILIMIXED OILS) STATE CODE 221
<br /> NONaRCRA HAZARDOUS WASTEp LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE
<br /> OTHER: n r. < d f , P,F . dr,. , r . r Addill
<br /> DESIGNATEDTSOP: AMEPcal(7l+NVA•( ,I.t• 'vVVANT ¢'rNrAfSTRIAL DlliVt , `iUlffiMARA
<br /> IU . ulGttri':Tt?Pd , ,C '/t ft .'", .5 ,, (t1(I<Ir "P };.dtsq (`d, � , l)t)01 •t ;r''I
<br /> ALTERNATE TSQF:
<br /> E,af983TI $. O , �SrJ> ull: (41h?t £'" Ni1PY1 R ^.fait
<br /> PAPUA
<br /> DRUMS EMPTY DRUMS: FACILITY:
<br /> PANAMANIAN
<br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX)
<br /> My signing below I hereby certify that:
<br /> (Waste oll generatorlicustomer MUST check ONE of the following three boxes)
<br /> U 01) 1 haw not mixed any of the waste dsaadbad above with any other htaardoue waste, the total halide oontent 10 LESS than 1 ,400 ppm, and the waste dog not contain any PCs*. i haw
<br /> Pod ►nth the requlrennents of the appuoabre caufornta used oil manstsmont mgul■tfona to detatmine this to true. I agree to accept the eddinonal charges for the disposal of this waste It
<br /> the InformtlWh 1 have provided about this west* Pa Inoormat
<br /> ❑ 021 have not mixed apy of the waste descrim above with any other hazardous waste, the total halide content Is GREATER than 1 ,000 ppm, and the waste doe► Rat contain any PCsa, i
<br /> crave provided proper dgcunlntatlon to World Oil Environmental Said to rebut the presumption that this waste was mised with other hazardous waste, 109M to accept the additional
<br /> oha+ge■ for the dlopm of th a welts if the Infotmatlon 1 have provided about this waste Is Inoorreet
<br /> Q 3d) Thle w#eta Is from it tank which coileour wsato all from houashold ^dodbyoumalf" (DIY) andtor conditionally o'zempt small quantity generator (CE150) aources, To the best W my
<br /> knowfsdge, the only waste on contained In my DIY/ CESQO collection tank Is Soley from DIY andfor CESOO sourceb t have not mixed this waste cit with any other hazardous waste ar waste all
<br /> from otter Sources. I agree to eecspt the additional charges for disposal of this waste it the information I have provided about this waste Is incorrect
<br /> (Ali generators/ customers MUST read the following text
<br /> I ohtlfy Viet 1 have a program In plea to reduce fru volume and toxicity of whsto ganereted to the degree I have dstermlned to bs economically practicable sne that 1 have eeleoted the
<br /> ONOIloabre mathad of treatment, atoregs, or dlopaaal currently available to me which minimizes the present and future threat to human ill# and the ohvlronmant,
<br /> This Individual signing In the space net ronn below on behalf of customer represents and warrants that lWahe has the authority to bind customer, that the forgoing de*oripllans of waste
<br /> by the th Lowe ard e true
<br /> e too
<br /> accurate is own tidereverse keds and
<br /> flips ittod,a toady
<br /> toy transpotudon in accordance with applicable state and federal regulations, and that customer shall sblae
<br /> gervlc# orders th a associated hazardous waste manifost (alther ane specific or consolidated) are su act to an EPA res. These feels cover the EPA pasa•thtovgh fee and administration
<br /> of itis ante pr°' am. 7hesa Pass very based on f taniMat type, Applicable fees will appear on your bliiins invelos•
<br /> Custom r Sign tur Date r' 6flyerjSignature Dista.
<br /> Prin NameArlt Drtvfrr Name
<br /> 1 1P
<br /> 60 39vi tie ads "`dlt1N0IiVNJ31NI 815L89660Z 0Zam6Z LZOZ /8Z /01
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