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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: owor&DOIL N3545864 <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICEST. <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H SPEEDEE OIL CHANGE 1-800-727-2879 <br /> P 245 W LOUISE AVE WWW.WORLDOILCORP.COM 245 W L.OUISE AVE <br /> D TRANSPORTER EPA#CAD028277036 <br /> T MANTFC:.A,CA 95336 MANTECA, CA 95335 <br /> 0 (209) 825-5823 (209) 825-5823 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> SPE080 f ZOUTE 12 ADAM SCHEDULED-! <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 4/6/2021 3/31/2021 CAL000351460 yrs9� C7� �T'07 <br /> FLIPART# DESCRIPTION OTY UNIT PRICE OTY P/U TOTAL <br /> PFO USED OIL/ MIXED OILS 550 11(� <br /> Z �i <br /> BA7CJ 9-__ 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 /> OTHER: <br /> DESIGNATED TSDF: @p <br /> ALTERNATE TSDF: <br /> Crosasuaars Arrniint Managrsr Sam Raari <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> 751) g below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ave 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.f 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 /> LI#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.1 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'(DIV)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is soley from DIY and/or CESQG 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 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'r <br /> ' ning 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 rue 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 therms and Conditions on the reverse side of this Service Order. <br /> S h an assoc' ted hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. es aes cover the EPA pass-through fee and administration <br /> ofrogram. ese fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> 415121 <br /> C sgnature Date gnature �JDate <br /> 1 M'�11 C—. <br /> Print Name Print Driver Name <br />