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FOR SERVICE CALL: SERVCC ORDER FORM iVO.WOE8004-8(8/18) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERv10E.oFIDER N0. 1»800�7�7,�287Q' _ l FOR ACCOUNTING GALL; ��D O�� _ 2 562-231=1560 ENViRC?Nh1EN1'AL SERVICES�I 7300 CHEVRON WAY,DiXPN;CA 95620 ! 11REcS ON ' f 287,46 1-8Q0 727 2879 QUEST R-ES ?URCE M(.';,T- FIRES70# F :20 1-7. HAMMER LANE WWW.WORLDOILCORP.CO.M 3481 IILANO PARKWAY 6 TRANSPORTER EPA#CAO028977036 209) 951.2473 (972)_4£;4-0004 CUSTOMER# PURCHASE ORDER#. ROUTE# TRUCK# CONTACT NAME. ORDER TAKEN BY HALIDES L DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BiLL of LADING/MANIFEST# 6111t2021 ai212021 CAL00_0366211Cif ✓r � -7 PART,-# DESCRIPTION QTY UNIT PRICE QTY'P/U TOTAL AF E.1 HYLENE GLYCOL SOLUTIONS 60 TOTAL CASH REWM CHECK , WASTE DISPOSAL INFORMATION" NON-RCRA HAZARDOUS WASTE,.LIQU 0(USED OIL/MIXED AILS) STATE CODE 221 NON«RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE OLYCOL SOLUTIONS) STATE CODE 133 OTHER. [OESIGNATEDTSQF: ENIARGNMENTFA. GERE )644 ,. 6a ALTERNATE TSDF: ' DRUMS PIU; EMPTY RRUMS . FACILITY..- BSC GENERATOR WASTE,CERTiFICATION-(PLEA$E CHECK THE APPROPRIATE BOX) sy signing below l hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) st)i have not mined any of rhe waste described above with any other hazardous waste, total twllde content le LESS than i Ago ppm,and the waste does not contain any pCfis.I have coinpitedwith the requirements of the applicable California used oil management regylattons to determine this i@ true:i agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is incorrect e2 t have not mixed any of the waste described above with any other hazardous waste,the total halide content Is GREATER than 1,000 ppm,and the waste does not contain any PCBaf I have provided proper documentation to World Oil Environmental Services to rebut the presumptlon that this waste was mixed with other hazardous waste.i agree to accept the additional charges for the disposai of this waste if the information t have provided about this Waste Is incorrect 03)This Waste is from a tank which collects Waste'oil from household"dolt-yourself"tPIY)anWor eondhlonahy exempt small quantity generator(GESQ¢)sources.To the_beat of my. knowledge,the only waste ol1 contained In my ow QF60 coliection tank la$clay trot"OtY amt/Qr CESQCx'aov►ces,l have not mined this Waste oil with'any other hazardous-waste or Waste oil from Ciller soyrcett.:I agree ropccept ureapdmoner chargw.lor,otapeiwtot.0»s wgoro;rr to (Ali generators/customers MUST read the f011awing text i cerlNy that i have a program in place to reduce the volume and toxlolty of waste generated to the degree i have determined to be economically practicable and that I have selected the precticat{fe method¢f treatment,storeys,4r dispeasl curentiy svalTable to me whichmintmbtes the pi'esent.and future to human life and the envtronmenh This Individus si in in tha space set forth below ot'Whalf ofcustomer represents and warrents that hehhe has Nie authority to bind customer,that Frye forgoing descriptions of wast* and materials a nd ceurate as packaged,marked,and lafreled,a""-dy for transportation In arcoMancewith;appficabie state and fetlaml regulations,ells!thM custpmer shat)ehldp' by the Stands T ri Conditions ort the reveres aide or this Service tlrder. of the ant rder, va ous weals nranifsst(either slte specific or eonsolldatert)ere subiept to an Efllt Fes•Tineas fees cover the ERA p@sa-thr{fugh tea and adminisi►atlon Service Order r t,ed hazard D ry based An Maniraflt tajpe• Appucehla fees Will appear on Your hitting invote6 j f+ Custorft e Date Drl err Signature if Date �1 11�7� Print Name Print river Name