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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: <br /> 562-231-1550 vWORLDOIL <br /> ENVIRONMENTAL SERVICES- <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H _k' <br /> QUESTi RESOURCE MG 1R.L,_) <br /> 1-800-727-2879 <br /> P <br /> P 348" P"-Al"I'() Pi�RK'AiAY <br /> WWW.WORLDOILCORP.COM <br /> E <br /> TRANSPORTER EPA#CAD028277036 <br /> DTHE COLONY, X 77C56 <br /> 0 1 4 3_2 ,972) 464-0004 <br /> CUSTOMER # PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> FE. 12 <br /> y0of scr <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> A L 0 30:a-6 6 2 11 <br /> 0,29 16,2 yi 3 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> Z� <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 /> 1 "NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> 'y­;"� S:�riv 1 C, 0 <br /> -3E 5, CA;5�-iR f�� -1875,CA!.-�,' <br /> DESIGNATED TSDF: 4. �4' <br /> ALTERNATE TSDF: <br /> 4=,ourit r0ariage,. San'i React <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 /> LJ#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 /> #2 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 does 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 it the information I have provided about this waste is incorrect <br /> J#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.I have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.I 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 p gram 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 <br /> have a P gram in place <br /> practicable method of eatment,storage,or disposal currently available tome which minimizes the present and future threat to human life and the environment. <br /> the - <br /> d a .r <br /> 0 <br /> This individual sign n the e set forth below on behalf of customer represents and warrants that he/she has the authority.to bind customer,that the forgoing descriptions of waste <br /> and materials are tr da ur 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 Standard Te n on i se side of this Service Order. <br /> Service Orders <br /> R oc t; <br /> ers i sociat d manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of fe <br /> the eManife p fe Manifest type. Applicable fees will appear on your billing invoice. <br /> X 2i 3112 2 <br /> I <br /> Customer Sign;artel Date D�iag n a t u re Date'T <br /> V i Me4-p <br /> , I IAJ <br /> Print Name Print Driver Name <br />