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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA (8/18) 1-800-727-2879 SERVICE ORDER NO. FOR ACCOUNTING CALL: �®��® ®'� N3614174 562-231-1550 ENVIRONMENTAL SERVICES, SPEEDEE OIL CHANGE 7300 CHEVRON WAY,DIXON,CA 95620 1-800-727-2879 245`/kf LOUISE AVE WWW.WORLDOILCORP.COM 246 Ulf LOUISE AVE MANTECA,CA 95336 TRANSPORTER EPA#CAD028277036 (2Q9) 825-5823 MANTECA, CA 95336 (209) 825-5823 CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES SPE080 ROUTE 12 , ADAM SCHEDULED-1 )ATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# 6/1/2021 5/2612021 CAL000351460 oZ 16'�FG l 1 L4 iTil�_ PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL PFO USED OIL MIXED OILS 570 5-7 BATCIi # TOTAL 'ASH REC'D: CHECK# /101 WASTE DISPOSAL INFORMATION ) NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: ? DESIGNATED TSDF: ASBURY,ENVlkONMENTAL SERVICES-CERES 1920 MORGAN RD CERES CA 955358(209)541-1825,CAL000393680 ALTERNATE TSDF: Crass Streets: Account Manager Sam Read IRUMS P/U: EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) 3y signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) 101)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.l have ;omplled 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 he Information I have provided about this waste is incorrect :1#21 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 lave 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 :harges for the disposal of this waste if the information I have provided about this waste is Incorrect :1#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 mowledge,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 rom 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 (All generators/customers MUST read the following text 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 wacticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. rhis individual signing in the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer,thatthe forgoing descriptions of waste and materials are true and accurate as packaged,marked,and labeled,are ready fortransportation In accordance with applicable state and federal regulations,and that customer shall abide 3y the Standard Terms and Conditions on the reverse side of this Servlce Order. 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 3f the eManifest program.These fees vary based on Manifest type.Applicable fees will appear on your billing invoice. l� , 2/ 2t / z/zi customer Signature Date Iver Signature Date � YC-" rSle�V- 3rint Name Print Driver Name