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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: GWORLDOIL <br /> N36927562-231-1550 <br /> ENVIRONMENTAL SERVICESo, <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> P CENTRAL VALLEY WASTE SERVICES INC C 1 aoo-727 2a7s WM OF SACRAMENTO NEVADA AR <br /> P 1333 E.TURNER RD WWW.WORLDOILCORP.COM PO BOX 4745 <br /> E <br /> **SEE NOTES FOR VAC** TRANSPORTER EPA#CAD028277036 <br /> o LODI,CA 95240 PORTLAND,OR 97208 <br /> (209)333-5655 (916)294-4035 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> CEN644 F 10UTE 12 q©a -ASHLYNN WILLIA SCHEDULED-1 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# - BILL of LADING/MANIFEST# <br /> 6/10/2021 6/2/2021 CAL000194471 :12�2�/%o <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> PFODI USED OIL i MIXED OILS-DIY 210 d <br /> MONTI-1)11.BILLING SEND TO SANTA FE OFFICE,AKA:LODI RECYCLING,LODI TRA N FER STATION Checkwith I TOTAL <br /> CASH REC'D:1 CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCFTA HAZARDOUS WASTE,LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF:�t58t7RY-ENMR�ENTAt-SE 0-MORGAN�CER , 80 <br /> ALTERNATE TSDF: <br /> C1 abs Streets, -11 904 pm Bt:Aw�ff Pq Almoun,Manage.Sann Read <br /> DRUMS PIU: EMPTY DRUM: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By slgning below i hereby certify that: <br /> ������[[[((( (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 1)t have not mixed any of the waste dencdbed above with arty other hazardous wamo,the total halide content Is LESS than 1,000 ppm,and the wade dors not contain any PCBs.I have <br /> c plied with the requirements of the applicable California used oil management regulations to determine this In true.1 agree to accept the additional charges for the disposal of this waste If <br /> tho Information I have provided about this waste Is Incorrect <br /> ❑112 1 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 dots not contain any PCBs.i <br /> have provided proper documentation 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 Inlormallon I have provided about this waste Is Incorrect <br /> ❑63)This waste Is from a tank which collects waste oil from household"do-it-yourself'(DIY)andfor conditionally exempt small quanUty generator(CESGG)sources.To the best of my <br /> knowledge,the only waste ell contained In my DIY/CESGG collection tank Is soley from DIY and/or CESGG sources.I have not mixed this waste oil with any other hazardous wasto or waste oil <br /> from other sources.I agree to accept the additional charges for disposal of this waste It 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 he economically practicable and that i 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 authorlty to bind customer,that the forgoing desalpilons of waste <br /> and materials are tam and accurate as packaged,marked,and labeled,are ready for transportation In accordance with applicable stale and federal regulations,and that customer shall abide <br /> by Ilia Standard Terms and Condition-on the reverne side of fhls Service Order. ' <br /> Service Orders with on associated hazardous walla manifest(either elle specific or consolidated)are subject to an EPA Fee.Those fees cover the EPA pass-through fee and ndminletrallon <br /> of the eManlfcst program. tese fees vary based on Manllest type. Applicable fees will appear on your billing Invoice./-/_ <br /> n4- <br /> r Signature Date Driver Signa�tur/ee Date <br /> Print Na eP frP nt Driver Nam <br />