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�.�rr�+�n f-- f fa�rr�.'Iray..+n n•t— � — - - --- � — - - _ --- — <br /> FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: �®��® ®'L N3644759 <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES, <br /> S7300 CHEVRON WAY,DIXON,CA 95620 <br /> j SPEEDEE OIL CHANGE 1-800-727-2879 <br /> P 245 W LOUISE AVE WWW.WORLDOILCORP.COM 246 W LOUISE AVE <br /> D TRANSPORTER EPA#CAD028277036 <br /> T MANTECA,CA 95336 MANTECA,CA 95336 <br /> 0 (209)825-5823 (209) 825-5823 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> SPE080 CER-86 / ADAM SCHEDULED-I <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA* BILL of LADING/MANIFEST# <br /> 7/2/2021 6/23/2021 CAL000351460 O <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> PW PARTS WASHER WASTE 20 $0.00 7Z_U $0.00 <br /> PWSC1 PARTS WASHER SERVICE/RENTAL 1 $165.0 Y $179.03 <br /> BAT # <br /> 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 135 <br /> X OTHER: ,LIQUID(MUEGUS EF�rSt3LLFIGN) State Gad a 13 - <br /> X DESIGNATED TSDF: woRi n oil RFcvciINa.9nnn N AI AmsnA sTRFFT,_cx2n platy.CA m999.(310)537-7100,CATO@0013352 <br /> ALTERNA DF: <br /> -- ----04-- Account Maria=Sam Read <br /> -UJ <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 /> ❑#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 documentatiol 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 /> »{ — <br /> C3#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.l have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.t 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 R <br /> practicA','eeod of treatment,storage,or disposal currently available to me which minimizes,the present and future threat to human life and the environment. <br /> This Ingning In the space set forth below on behalf of customer represents and warrants that helshe has the authority,to bind customer,that the forgoing descriptions of waste / <br /> and matrue 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 Terms a Conditions on the reverse side of this Service Order. I <br /> Serviceit n associated hazardous waste manliest(either site specific or consolidatedi Le subject to an EPA Fee.These fees cover the EPA pass-through fee and administration <br /> X <br /> ep gram.These fees vary based on Manifest type. Applicable fees will appear(R your billing Invoice. <br /> I <br /> m\er Signature Date Driv i nature Date <br /> oe <br /> ed <br /> Print Name Print Driver Name <br />