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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: N3793264 <br /> ()WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICESTM <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H SPEEDOE OIL CHANGE 1-800-727-2879 <br /> P 245 W LOUISE AVE WWW.WORLDOILCORP.COM 245 Ulf LOUISE AVE <br /> P <br /> MANTECA, CA 95336 TRANSPORTER EPA#CAD028277036 <br /> T MAN T ECA CA 95336 <br /> 0 (209) 825-5823 (209) 825-5823 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> CPR-86 RYAN iahernandez <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 11/15/2021 CAL000351460 /a/ •�.7 N, <br /> PART# DESCRIPTION QTY UNIT PRICE TY PJU TOTAL <br /> PF PAPER FILTERS PER DRUM 2 $85.0 $170.00 <br /> OFDR OIL FILTER DRUM REPLACEMENT- NO CHARGE 2 $0.00 $0.00 <br /> BAT # <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> XOTHER: NON-RCRA HAZARDOUS WASTE. gat r D(OILY PAPER/PLASTIC FILTERS/DEBRIS) State Code 352 <br /> X DESIGNATED TSDF: YES MANAGEMENT, INC.,6500 US HIGHWAY 95,YUMA..AZ 85355 <br /> ALTERNA <br /> Crops-Streets, Account Manager: Sam Read <br /> DRUMS P L <br /> EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> J#1)1 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 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 1 have provided about this waste is incorrect <br /> J#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.1 <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 additional <br /> charges for the disposal of this waste if the information I have provided about this waste is incorrect <br /> J#3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIV/CESOG collection tank is Soley from DIY and/or 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 1 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 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 Conditions on the reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These f or the EPA pass-through fee and administration <br /> f t e e�Aanif st program. hese fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date natureate <br /> C,61/_� <br /> /x- <br /> Print Na a rent Driver Name <br />