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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICEASBURY ENVIRONMENTAL SERVICES, DBA FORM NO. WOES004-B pIQ) <br /> 1-800-727-2879SI~RVICE ORDL�R NO. <br /> 1=0F1 ACCOUNTING CALL: OWORLDOIL <br /> 561'•231-1550 <br /> ENVIRONMENTAL SERVICES- `� ! <br /> H 7300 CHEVRON WAY,DIXON,CA 35620 �Q <br /> P 1-800-727-2879 <br /> i� WWW.WORLDOILCORP.COM <br /> o TRANSPORTER EPA#CAD028277036 <br /> n <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DAT/"REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST 9 <br /> PART# DESCRIPTION + UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) <br /> OTHER: STATE CODE <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> rlsk.uwd M8elauol ;a,111 <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> WY signing below 1 hereby corlify that: <br /> (Waste oil generator/cuStomer MUST check ONE of the following three boxes) <br /> 41#1)1 have not mixed any of the waste described above with any other hazardous waste,tiro total halk►e content Is Legg than 1,000 PPm.and the waste dogs Rol contain any peon.I have <br /> oomplfod wile the requtroxnonts of the applicable California used oil managetrtent reguiationa to determine this is true.1 agew to 000"the additional charges for the disposal or tl%6 u <br /> the Information I have provided about this waste Is Incorrect <br /> U#2 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is 03REATER than 1,000 ppm,and the want*dose not contain any rx'A.,.I <br /> ilavo providod proper documentation to World Oil Environmental Services to rebut the prosumptlon that this waste was mixed with other hazardous waste I agree,to Dec"the adrlhl <br /> Outruns for the disposal of this waste if the Information i have provided about this waste Is Incorrect olat <br /> U G3)Title waste Is from a tank which collects waste oil from household"do•it-yourself"(01Y)andlor conditionally exempt small <br /> kuuw"G,1110 only waste oil contained In my DIY!CESW collection tank Is soley from DIV and/or CESOO sources.I have not mixed thin <br /> ���(C h any themes.To lee boot of illy <br /> from other sources.109000 to accept the additional chorgos for dispoabi of this waste If the Information I have zeta warns oil with any other tmmrdoua oasts or wtlsto ell <br /> provllsd abeat this W*eta to Incorrect <br /> (All generators/customers MUST read the following text <br /> I certify that t leave a program in Place to reduce the volume and toxicity of waste generated to the degree 1 have dietermined to but eooxwmloally practicable and that I have solected the <br /> procticablo/method of treatment,storage,or disposal currently available to me which mlnimima the present and future throat to human life and the envlroxmlont <br /> This individual signing in ties sprca not forth below on beholl of customer to Me and warrants that he/she has thethatp <br /> by Ilea Standard Teland alaterials are rms and ardxdaCpnalilons on"toypane versa marked,and <br /> nd lames ed,are <br /> ready for transportation in aecordanos with app le"afata and fe0MI t f°lured^ d at Customer <br /> of welts <br /> regulations. thatcuaWmarshall oWxdo <br /> 1ieOdeth an associated hazardous <br /> waste <br /> manifest <br /> 'althorails /isted)am submit to an EPA Fos_ Tease las covor the EPA puna-through foo aeul adndnloiraibnof 1crs .These faaaManifest typo. <br /> Applicable fees will appear <br /> on your billing Involm. <br /> Customer Signature Date Driver Slgrt— Date <br /> Print Name Print DriveName <br />