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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: N3641636 <br /> 562-231-1550 WORLD OIL <br /> ENVIRONMENTAL SERVICES,. <br /> H SPEEDEE OIL CHANGE 7300 CHEVRON WAY,DIXON,CA 95620 <br /> I 1-800-727-2879 LOUISE AVE <br /> 245 W LOUISE AVE <br /> P 245 tiff WWW,WORLDOILCORP.CONi <br /> E <br /> ° MANTECA,CA 95336 TRANSPORTER EPA#CAD028277036 MANTECA, CA 95336 <br /> 0 (209)825-5823 (209) 825-5823 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> SPF-090— ROUTE 17247— ADAM SCHEDULED-1 <br /> qco <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 6/29/2021 6/23/2021 CA L000351460 o2--t626 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U d TOTAL <br /> PFO USED OIL/MIXED OILS 570 <br /> 00 <br /> BAT # <br /> 1 TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> o NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> X DESIGNATED TSDF: ASBURY ENVIRONMENTAL SERVICES-CERES 1920 MORGAN RD CERES CA 95358(209)541-4826 CALa00393680 <br /> ALTERNATE TSDF: <br /> ri Cross Streets: Account Manager Sam Read <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By sig ng 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 /> compiled 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 /> 0#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 <br /> have provided proper documentation to World 011 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 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 1 have provided about this waste is Incorrect <br /> (All generators/customers MUST read the following text <br /> I certify that 1 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 f 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. a fees cover the EPA pass-through fee and administration <br /> of the Manifest program.These fees vary based on Manif t type. Applicable fees will appear on your bllling Invoice. <br /> r ( ,z <br /> �Cu tomer Signature Date rive ' nature Date <br /> Print Name Print Driver Name <br />