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FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004- 13 (8/18 ) DIXON OFFICE ASBi RV ENVIRONMENIT'AL SERVICES , DBA SERVICE ORDER NO. -1 - 800-727-2879 FOR ACCOUNTING CALL : WORLD � )>- 562 - 231 - 1550 15 U t to 5 2� -i I22 ENVIRONMENTAL SERVICES - 11 7300 CHEVRON WAY, DIXON , CA 95620 1 - 800 -727 -2879 = WWV1/ - WORLDOILCORP. COM n T TR APISPORTER EPA # CAD028277036 CUSTOMER # PURCHASE ORDER # ROUTE It TRUCK # CONTACT NAME ORDER TAKEN 13Y HALIDES 14 DATE REQUIRED DATE ENTERED NEXT SERVICE DAIE CUSTOMER EPA # BILL of LADING/ MANIFEST # PART /t DESCRIPTION OTY UNIT PRICE QTY P/U TOTAL rl 00 LVTOTAL CASH C.REC ' D : , _ CHECK #Elm.__ ______ __ WASTE DISPOSAL INFORMATION NON - RCRA HAZARDOUS WASTE , LIQUID ( USED OIUMIXED OILS ) STATE CODE 221 NOWRCRA HAZARDOUS WASTE , LIQUID ( ETHYLENE GLYCOL SOLUTIONS ) STATE CODE. w_ DESIGNATED TSDF : , .. a ALTERNATE TSDF : I A, -_--_—. DRUMS P/U : EMPTY DRUMS : ___ _ __ FACILITY : _. _ SSC GENERATOR WASTE CERTIFICATION ( PLEASE CHECK THE APPROPRIATE 00X ) By signing below I hereby certify that : (Nilaste oil generator/ctastorner• MUST check ONE of the following three boxes) i ,r1 ) .1 have not mixed any of the waste dascnbn lr compiled With the requirements of lira appiicabid California used oil mmiagallmal regulations to determine tills is buo- I agree to accept the additional charges for the dlsposal of this waste If the liiformatlon I have provided about this waste is incorrect E2 I nave not mixed any of the waste descrlbee above with any other hazardous e, aste. the total halide content is GREATER than 1 ,000 ppm , and the waste does not contain any PCBs. 1 have provided proper documentation to World Oil Environmental Services to robut the presumption that this waste was mixed with other hazardous waste. I agree to accept the additional charges for the disposal of tilts waste if the information I have provided about this waste is incorrect 1 43) Tills waste is from a lank which collects waste oil train household "do-it-yourself" (DIY) and/or conditionally exempt small quantity generator (CESOG) sources. To the best of my knowiadge, the only waste oil contained In my OIY1 CESOG collection lank is soley from DIY and/or CESOG sources. I have not mixed tills waste oil with any other hazardous waste or waste off Iron other sources . I agree to accept the additional charges lot dlsposnl of this waste if the information I have provided about this waste Is incorrect ( Ail generators/ customers MIDST read the following text I certify that I have a program in Place to reduce the volume and toxicity of waste generated to the degree f have determined to be economically practicable and that I have selected the practicable method of Ireaunenl , storage, or disposal currently available W me which minimizes the present and future threat to human life and the environment. This ind6olldoal 31rining In 1110 space set lorlh beloyr all behalf of cuslohtur represents and prarrants that hWshe has the authority to bind customer, that the forgoing descriptions of waste and motenats ate true and accurate as packaged. Marked: and labeled, are ready for transportation in accordance with applicable state and federal regulatl'ohs, and ihM customer shall abide by tiie standard Terms, and conditions on the revere 9ohle of-this sgrvice,older. Service Orders with an associated hazardous waste manifest (either site specific or consolidated) an. subject to an EPA Fee. These fees cover the EPA pass-through tee and administration S of the oManifosl prOgrnt These fees vary based on Manifest type. Applicable fees will appear on your billing invoice . t . � p20 r � r ate Customer Signature Date D Signate D ur