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FOR SERVICE CALL: SERVICE.ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: ��■^^ ��yy ^ N3647130 <br /> 562-231-1550 �WORLD RL V Q I L <br /> ENVIRONMENTAL SERVICES. <br /> S 00 CHEVRON WAY,DIXON,CA 95620 <br /> H STOCKTON SCAVENGERS ASSOCIATI(A 1-800-727-2679 WM OF SACRAMENTO NEVADA Al <br /> P 1240 NAVY DR PO BOX 4745 <br /> P WWW.WORLDOILCORP.COM <br /> D MONTH LYVIFO TRANSPORTER EPA#CADG28277036 <br /> T STOCKTON, CA 95206 PORTLAND, OR 97208 <br /> 0 (209)460-3912 (916)294-4035 <br /> CUSTOMER# j PURCHASE ORDER# ROUTE# TRUCK#_ CONTACT NAME ORDER TAKEN BY HALIDES <br /> ST0621 10110807 OUTS 12 S�Co � iahemandez <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 6/28/2021 CAD980737225 o2—r 5 2q 3O 60o'lc <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> AF ETHYLENE GLYCOL SOLUTIONS <br /> ONLYEG OIL PIU&HAZ p/u -USE USAB05 FOR DIYTANKANJELICA 209 460 3925 REQUESTOR:AMEDINA4@W,LCOM <br /> 1 USE P 10110807-2 FOR VAC BATCH* TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE 133 <br /> OTHI=R: <br /> DESIGNATED.TSDF: WORLD OiL ENVIRONMENTAL SVCS-CERES 1920 MORGAN RD CERES CA 95358 209 541-f 825.-91-09— <br /> ALTERNATE TSDF: <br /> Cross Stre+xts: P U EG OIL-HA?P1U RI= UESTOR: D4AWM,COM AlXalunt Mena er.Sar.Read <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSG <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 /> ❑41)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 all 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 /> ❑#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 PCBs.I <br /> have provided proper documentation to World 011 Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the addluonal <br /> charges for the disposal of this waste If the information I have provided about this waste Is Incorrect _ <br /> ❑0)This waste Is from a tank which collects waste all from household"do-it-yourself'(OIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the gnlywaste oil contained in my DIY!CESQG collection tank Is soley from DIY and/or CESQG sources.I havo not mixed this waste all 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 /> 1 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 tha present and future threat to human Ilia and the environment. <br /> 'rbls Indlvldual signing in the space sel forth below on bohall of customer represents and warrants that havho ha,the authority to Lind customer Thal Ihn forgoingdescripnons otwaste <br /> and maierlals sit frueand accuralc a:packagrd,marked,and labeled,are ready fartrensport allnn In acco rda rice with appllcabia slale and fedem3 regulations,and th at custo mer shall abide <br /> by tha Standard Terms and Condllions on the arse side of Ihls Service ardor. <br /> Service Orders Milian assoclate d hazardo u a wasto mantled(ellhersile Spec, <br /> licer ccnaolldaled=are sublectto an EPA Fee.These fees covartha EPA pass-through fee and administration <br /> of the laNlanlfesl program.These fees vary based on FAan[fest type.Appllcabla lets wlII appear on your Wiling lnvaIca. <br /> f tv Ow SGt � 9i i2 l�t <br /> Customer Signature Date nature <br /> CL( Date <br /> �Tv-- I r lrC1�l� <br /> Print Name Print Driver Name <br />