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FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004-B (8/18) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA SERVICE ORDER NO, 1 -800427-2879 FOR ACCOUNTING CALL RLR OIL 562-231 - 1550 WORLD /(; owl K ENVIRONMENTAL SERVICES ,a �J 5 N 7300 CHEVRON WAY, DIXON , CA 95620 H 1 -800-727-2879 1 PROTOUCH AUTO REPAIR E255 MOFFAT BLVD WWW.WORLDOILCORP. COM 255 MOFFAT BLVD D TRANSPORTER EPA # CAD028277036 o MANTECA , CA 95336 MANTECA, CA 95336 (209) 239-9250 (209) 239-9250 CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES PR0110 { OUTE 12 (f �� ALDO SCHEDULED- 1 DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # 211512021 2110/2021 CAL0002.99266 p� jS � y � 20 �rr PART # DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL - mac, .. � L.!✓ ! 1 0 U 7'NiT�`c 4 X11, S 150 $000 $ 0 00 BATC # TOTAL CASH REC' D : CHECK # 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: - - ) _ , 8a ALTERNATE TSDF: a _ dv 1 ct a is G fc _ a, , r , DRUMS P/U : EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) By signing below 1 hereby certify that ' (Waste oil generator/customer MUST check ONE of the fallowing three boxes) 0 #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 compiled with the requirements of the applicable California used all management regulations to determine this Is true I agree to accept the additional charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect 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 have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste 1 agree to accept the additional charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect ❑ #3) This waste Is from a tank which collects waste all from household 'da•lt ycurself" (DIY) andfor conditionally exempt small quantity generator (CESOG) sources To the best of my knowledge, the only waste all contained In my Mir CESOG collection tank is solay from DIY and/or CESOG sources I have not mixed this waste oil with any other hazardous waste or waste oil from other sources 1 agree to accept the additional charges for disposal of this waste If the Information 1 have provided about this waste is Incorrect (All generators/ customers MUST read the following text I certify that 1 have a program In place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically practicable and that # have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human life and the onvironinonL This individual signing in the space sot forth below on behalf of customer roprosonts and warrants that he/she has the authority to bind customer that the forgoing descriptions of waste and materials are true and accurate as packaged, marked, and labeled, are ready for transportation in accordance with epplicabto state and federal regulations, and that customer shall abida by the Standard Terms and ,Conditions on the reverse side of this Service Order Service Orders with an associated haiaidooa waste m its1 (alther site specific orconsoiidated) aro sub act io an EPA Fee These fees cover the EPA pass-through fee and administration o eeManlfestprogram Thesafeos rybasedon `M�,Ifeattypo Applicable fees will eppaaronyour bpiinginvoice L _ / t2i2 / 3 g ,2f Custo r lgnature Qa`te Dr VON Date Print Name Print Driver Name