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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA ffSERVICE ORDER NO. <br /> 1-800-727-2879 i; <br /> 4. ACCOUNTING CALL: <br /> 31-1550 WORLD OIL <br /> ENVIRONMENTAL SERVICES- <br /> 8 7300 CHEVRON WAY, DIXON,CA 95620 <br /> " STOCKTON SC��VENGCR5 ASSOCIA f It�P l WM OF SACRAMENTO NEVADA A <br /> 1-800-727-2879 p,0, BOX 6700 <br /> P 1240 NAVYDR <br /> P I/(/N W.WORLDOILCORP.COM <br /> E MONTHLY WO <br /> D TRANSPORTER EPA#CAD028277036I I-AND OR 97228 <br /> T STOCKTON• CA 95206 POR <br /> i0 (209) 460-3912 t4 294-4035 <br /> CUSTOMER# PURCHASE ORDER # ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 00000t:M 111 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE OTY P/U TOTAL <br /> vIL FILTER DRUM REPLACEMENT - NO C;HAR+.7E <br /> PAPER FILTERS PER DRUM <br /> i'AL Pei&Kk7.PAt -USE t.W08 FOR MYTANK Y41JELICA 209 4610'3a5� EQL1ESTO! <br /> L.tAi c_ TOTAL <br /> -"�%H 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: +tL�-,=f iii dsa�lF �L"sLNJ iill`r' tr� !'k'=rii1: iiti'! i1lF`5 1 'r'1='�a; , <br /> DESIGNATED TSDF: "F`=,MAN-)ki F?V.1ff1T,INC.,6500 US HIC•t!•#{AY 95,YI)MA,Ate-8�3a5 <br /> ALTERNATE TSDF: <br /> RECjUESTOR: Alai=DINA4i��r�ftyl.i-`OtVJ Acwunt Man4ger Sam R{is : <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 /> 0 #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 /> 0 #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.1 <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.1 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 /> Q #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 /> individual <br /> in the <br /> ace <br /> forth below on <br /> of <br /> er <br /> esents and warrants <br /> a�is atenels are true and accurate astpackaged,marked,andabelednarerreardy for transportation In atccordle has ance will applicable stato tnd custorner,e and federalthat the regu regulations,and that custome�shall abide <br /> Standard Terms and Conditions on the reverse side of this Service Order. <br /> ,ce 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 /> I of the eManifest program. These fees vary based on Manifest type, Applicable fees will appear on your billing Invoice. <br /> �s / IZ / 70 <br /> -est -mer'Signature Date -- <br /> Driver Signaturd 1-2 <br /> t ( ✓ �.. ', Date <br /> Print Name <br /> PrinADriv <br /> Name �`� <br />