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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: 111111111111FIm <br /> WORLD OIL i i3d$Ei$ $ <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICESTM <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> I SPEE DFE Cil CHANGE 1-800-727-2879 <br /> P :24,�VV '_OU1SE FIVE' WWW.WORLDOILCORP.COM 245`,A; ,,0U�i;rE AVE <br /> D TRANSPORTER EPA#CAD028277036 <br /> T !Vi, r4"EC;I�, C; �3 F? �riF4;'`v'I-,�_ A. CA :35336 <br /> ;2091 525-5$2 <br /> ;2091 325-5823 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> SPE-087 C=R: $t '��� �0 ;'v!RC' S V smartn ez. <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 51-n2.: :A1Uvnv 5146J ©ZCS z���_0 <br /> nC1'3 <br /> PART# DESCRIPTION OTY UNIT PRICE QTY P/U TOTAL <br /> EMS EVA' 'FEST EPA FEE & AD I!,"C - SITE SFECIFiC ru"iANi=E $25.00 <br /> 5 5-1") V1 55 5.]ALLONl 017 'DRUPdI (RECONDITIONED) 1 $0.30 ( $0.00 <br /> OLASS OL&A :S E t DRurV55 GL DR $250.0 C $250.00 <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 <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> street. Ancaunt Manag r Sam Raad <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.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 I have provided about this waste is incorrect <br /> ❑#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 /> ❑#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 1 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 on the reverse side of this Service Order. <br /> ervice ers 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 /> f t e eM 'fest program. These f es vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> a4i / <br /> ustomer i nature Date DriverSiiggjnaatu]riT Date <br /> AVI-0 1-e <br /> Print NIlime Print Driver Name <br />