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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: WORLD OIL <br /> N.3450894562-231-1550 <br /> ENVIRONMENTAL SERVICEST. <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> HS `GDEF tit ..1 `la` 1-800-727-2879 <br /> P2 45 VJ l-CURSE AVE- 245N LOUISE AVE <br /> P WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> T MAP`.1TE'(1- 3,,;'1A 9. 336 MANTECA, CA 95336 <br /> ° (;2019) 325-582.3 <br /> (209) 825-5823 <br /> CUSTOMER+ # PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> a CJ IJ CUTS 12 I fit LDll�ti'A SCI-Ir~DULED-1 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> ^2124120201 12,116/2020 CAL000351460 Oho b "-1,1 6 9 LrJ!,-)r- <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> ,R'{- ETHYL.-F::y E Gi-YCCL: 25 $0.0G nS $0,00 <br /> r1A7"C:i t� _ <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> /,NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE 133 <br /> OTHER: <br /> DESIGNATED TSDF: ASBURVENVIRONMENTAi <br /> ALTERNATE TSDF: <br /> l n3ss Streets: Account Manager Sam Read <br /> DRUMS P/U: 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 /> #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.1 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 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.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'(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/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 /> 1 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 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 fees 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. <br /> �, � ,�<�t11/' I 11 P- __57 / /c,( /Z/ <br /> Customer Signature Date Drivgn'ature Date <br /> V_//_r V) N % I ` 1 E"0-7� ]'1'' r r e17I � ft_ <br /> Print Name 1 Print Driver Name <br />