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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: N3859239 <br /> 562-231-1550 UWORLDOIL <br /> ENVIRONMENTAL SERVICEST. <br /> s SPEEDEE OIL CHANGE: 7300 CHEVRON WAY,DIXON,CA 95620 <br /> L <br /> H 245 W LOUISE AVE 1-800-727-2879 245 W LOUISE AVE <br /> I <br /> P <br /> P WWW.WORLDOILCORP.COM <br /> E <br /> D MANTECA,CA 95336 TRANSPORTER EPA#CAD028277036 MANTECA, CA 95336 <br /> T (209) 825-5823 (209) 825-5823 <br /> 0 <br /> C��Jpb PURCHASE ORDER# C%!IMT NAME qgRF4jft�� BY HALIDES <br /> # TRUCK# <br /> �DA tEREQUIRED DATE ENTERED NEXT bE IVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> C8L6Qnfj19&01 c).:2036,5 9,;4 TJt( <br /> P18M# 1 P'94@�a eli::s QT�.. UNIT PRICE QTY P/U TOTAL <br /> PRO UZ_4,—_�D 0\L., /'(\A I X-r <br /> BAI.CH� TOTAL <br /> CASH REC'D: CHECK# <br /> A WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OlUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> _X OTHER: VVUKLU 0 L LNVI RONAA EN!AL 1AICS-CL RES, 1920 MOROAN RD. CERE5,CA 9535B 209 541-1825,CACCOMM-68T <br /> H DESIGNATED TSDF: <br /> ALTERN <br /> CrOSSATE TSDF: <br /> Streetz: Account manager5amRea6 <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By gning below I hereby certify that: <br /> i <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 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 PCBs.I have <br /> Y.-I.Iied 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 incorrect <br /> LJ#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.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 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"(131Y)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DlY/CESQG collection tank is soley from DlY 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 it 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 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 an 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. Thes&LJees cover the EPA pass-through fee and administration <br /> of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. r-1 <br /> e-)?) <br /> 'Customer Signature Date Driver Signature Date <br /> )c PY'r R,�;, (P &,'� iri A-Z <br /> Print Name Print Driver Name <br />