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FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004- 13 (8/18 ) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA <br /> 1 -800-727-2879 SERVICE ORDER N0 . <br /> FOR ACCOUNTING CALL : WORLD OIL <br /> 562 -231 - 1550 <br /> ENVIRONMENTAL SERVICES ,:• <br /> S 7300 CHEVRON WAY , DIXON , CA 95620 <br /> 1 1 -800-727-2879 <br /> I <br /> P WWW . WORLDOILCORP . COM <br /> D D TRANSPORTER EPA # CAD028277036 <br /> T <br /> O <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING! MANIFEST # <br /> PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH RECD : CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON - RCRA HAZARDOUS WASTE , LIQUID ( USED OIUMIXED OILS) STATE CODE 221 <br /> NON - RCRA HAZARDOUS WASTE , LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER : <br /> DESIGNATED TSDF : <br /> ALTERNATE TSDF : <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 /> J 91 ) 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 /> 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 <br /> the Information I have provided about this waste is incorrect <br /> J #2 1 have not mixed any o1 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 if 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 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 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 authority to bind customer, that the forgoing descriptions of waste <br /> and materials are true and accurate 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 Terms and Conditions on the reverse side of this Service Order. <br /> Service 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 <br /> of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />