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FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004-B (8,118) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA 1 -800-727-2879 If SERVICE ORDER NO . FOR ACCOUNTING CALL: () WORLD OIL � -� ; w � ` 562-23 1 - 1 550 ENVIRONMENTAL SERVI`CESTM 7300 CHEVRON WAY , DIXON , CA 95620 _ - ' e IFI.._ v 1V800-727,,2879 _ IF, V!�t t l is '.� L: t ;+ a _ WWW.WORLDOILCORP.COM _ TRANSPORTER EPA # CAD028277036 J IF CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES L r . 'r .( �i-l-?—ATEE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING..' MANIFEST RI VI w� " FIT II � FFI ' ,' _ PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAa.��N� l 1` ED :SIL �� ' �I" � i...#-i �,f� aL, i �r �t5 `.`:" r IV TOTAL . IF j ':ASH REC ' D • CHECK # WASTE DISPOSAL INFORMATION I r`: NOWRCRA HAZARDOUS WASTE, LIQUID (USED OIUMIXED OILS) STATE CODE 221 14 NON - RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER : IF — - iDESIGNATED TSDF. :+.'3t € � .xtEf tf c:r fsa f t- aALTERNATE TSDF : - - — VIV -,FFV — I - I DRUMS PIU : EMPTY DRUMS : FACILITY: __ SSC GENERATOR WASTE CERTIFICATION, ( PLEASE CHECK THE APPROPRIATE BOX) By signing below 1 hereby certify that: (Waste oil generator/customer MUST check ONE of the fo9lowing three Foxes) zJ ;:1 ) I 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 - 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 it the information i have provided about this waste is incorrect J1 41 I 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 Pel3s, l 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 r.harges for the disposal of this waste if the information I have provided about this waste is incorrect - - -- - #3) This waste is from a tank which collects waste oil from household "do-it-yourself' (DIY) and/or conditionally exempt small quantity generator (CESQG) sources. To the best of my knowledge, the only waste oil contained in my DIY/ CESQG collection tank is soley from DIY and/or CESQG sources. I have not mixed this waste oil with any other hazardous waste or vrss_e C71 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 ;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 practicable and that I have selseted tine Practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human life and the environment. This individual signing_ e.-, in the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer, that the forgoing descriptions of wts and materials are trare and accurate as packaged, marked, and labeled, are ready for transportation in accordance with applicable state and federal regulations, and that customer shall a'_lid it F'Jy the Standard Teams and Conditions on the reverse side of this Service Order. - { Sz:,rice Orders with+an.associated hazardous waste manifest (either site specific or consolidated) are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration. of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear an your billing invoice. I IV / / t �� storrl6r Signature Date Drlv�r Signature Fate l� {f ✓ A Print Name Print Driver Name