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D � � 8 18) W I Cn �OFSaOa•B( � O N CD FOR SERVICE CALL: SERVICE ORDER FORM NO ORDER NO o N w N C� DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES,DSA SERVICE CD C) m 1-800-727-2879 F4 N = M FOR ACCOUNTING CALL: AM6 WORLD OIL `° v � 562-231-1550 3 ENVIRONMENTAL SERVICES,., CD CDD S 7300 CHEVRON WAY,DIXON,CA 95620 MGT CD 1-800-727-2879CD " FIRf STONS:#028746_ �]UEST Rk50UiZCE G sz Z) P 720 E. HAMMER LANE: WWW.WORLDOILCORP.COM 341,1 PLANO RARKY4 � P TRANSPORTER EPA#CA0028277036 E Cf) DM T 5 rOCKTO,; a210 THE coLorlr,TX 770" m 1209)951 (972)tifgr�rn, CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TgKEN BY HALIDES - O t7 DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA tl BILL 01 LADINW MANIFEST# q )�))! cin N QTY UNIT PRICE OTY P1U TOTAL PART# DESCRIPTION a o ft OL DR it IiFEiST i=ii=• '.-&ADMIN-bI I L 6PL(:IJAL MAI41[L,%i '1 TOTAL CASH RECD: CHECK# WASTE DISPOSAL INFORMATION NON RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS) STATE CODE 221 NON-3 RA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATED TSDF: +Nn 41 J i Al I;! lrjr.; '"rn f,i r.1 ALTERNATE TSDF: DRUMS PIU: •� EMPTY DRUMS: FACILITY: RSC GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) By signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) 1:10)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.%have compiled 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 the information I have provided about this waste Is incorrect LJ#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 PC9s.I 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 charges for the disposal of this waste if the information I have provided about this waste is incorrect J#31 This waste is from a tank which collects waste oil from household"it (DIY)and/or conditionally exempt small quantify generator sCE5OG)sources.7o the best of my knowledge,the only waste oil contained in my DIY/CESQG collection tank is wey from DIY andlur CESQG sources.I have not mined this waste oil with any other hazardous waste or waste all 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 (All generators/customers MUST 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 I have determined to be economically he epractnvironcable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future Ihreat to human 1'de and the environment. This individual signing in the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind and customer,that the forgoing thatdescustomer of wase O CD end materials are true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable scala and Iederal regulations and that customer shall abide (10 O by the Standard Terms and Conditions on the reverse side of this Service Order. licable fees will appear on your billing invoice. Service Orders with en aesoCiatod hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee.These fees cover the EPA pass-through lee and adminlslra on N of the aMarilfeat program. These lees vary based on Manifest type.App' pPMgnatUre J N // DrivDateCD O Date Customer Signature rn I , Print 00 o