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FOR SERVICE CALL: le 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: OWORLDOIL N3626453 <br /> 562-231-1550. <br /> 4 <br /> ENVIRONMENTAL SERVICESTm <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> I SPEEDEE OIL CHANGE 1-800-727-2879 <br /> P245 W LOUISE AVE 245 W LOUISE AVE <br /> P WWW.WORLDOILCORP.COM <br /> ° MANTECA, CA 95336 TRANSPORTER EPA#CAD028277036 ' <br /> °` (209)825-5823 MANTECA, CA 95336 <br /> (209) 825-5823 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> SPE-080 CER-86 w I Istantort <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# 'BILL of LADING/MANIFEST# <br /> 6/4/2021 CAL000351460 <br /> PART DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> OF DRAINED USED OIL&GASOLINE FILTERS(METAL) 3 $0.00 Al $0.00 <br /> <OFDR OIL FILTER DRUM REPLACEMENT- NO CHARGE 3 $0.00 $0.00 <br /> r <br /> RAT <br /> TOTAL <br /> CASH REC'D: CHECK# a <br /> WASTE DISPOSAL INO' MATION A <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE R <br /> OTHER: _ E:STATE 0,009 223 <br /> DESIGNATED TSDF: AMERICAN VALLEY WASTE OIL 521 INDUSTRIAL DRIVSUITE M.LIVINGSTON.CA 95334. (A00)732-4645.•f �Qp04430R <br /> ALTERNATE TSDF: 1 '" <br /> Cross streets, Account Manager.Sam Read Y <br /> DRUMS P/U:. 4_ EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK-THE APPROP TE BOX) <br /> By signing below I hereby certify that: <br /> r' (Waste oil generator/customer`•MUST check ONE of the following the boxes) <br /> .y <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 /> compiled with the requirements of the applicable California used oil management regulations to determine this is true.I agree to accept the additkinal charges forthe disposal of this waste if <br /> the information JPave provided about this waste is incorrect l <br /> ❑#21 have not mixed any of the wd'ste 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(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my OLY/CESCfq collection tank is soley from DIY and/or CESQG sources.I have not mixed thiswaste oil with any other hazardous waste or waste oil <br /> from other sources.I agree to accept the additional oharget;for disposal of this waste if the Information I have provided about this waste is incorrect <br /> (A%'enerators/customers MUST Dead the following text <br /> I certify that I have a program in place to reduce the yetume and toxicity of waste generated to the degree I have determined to be economically practicable and that 1 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 spacaset forth below on behalf of customer r9`Dtgsents 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,arl3 rt tn7 for transportation in accordance with applicable state and federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the revers zlde of this Sere'.% , - <br /> k, fir,. } <br /> Service Orders with an 8ssoclated hazardous waste an lesb(elther site spaciflc or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee aKadministratlon <br /> of the eManlfest program. These fees vary-based on Manifest type. Applicable fees will appear on your billing invoice. <br /> c6f6mer Signature Date Uri it Signature Date <br /> Print Name Print Driver Name ' <br />