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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: N3794287 <br /> 562-231-1550 OWORLDOIL <br /> ENVIRONMENTAL SERVICES, <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> IS T OCI:TON SiCAVENGERS�+.SSOCIATION 1-800-727-2879 WM OF SACRAMENTO iJF_VADA AFRI <br /> P 1240 NAVY DR WWW.WORLDOILCORP.COM PO BOX 4745 <br /> E <br /> D MONTHLY WO TRANSPORTER EPA#CAD028277036 <br /> T STOCKTON,CA 955206 PORTLAND, OR 97205 <br /> 0 (NI 460-3912 <br /> (916} 294-4035 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ST0621 MUST OBTAIN FJO ROUTE 1211,qj ANGELICA MAGANA SCHEDULED-I <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 11/23/202 11/17/2021 CAD98073722 <br /> PART# DESCRIPTION OTY UNIT PRICE OTY Pt//U l(TOTAL <br /> PFOC IY USED OIL/MIXED OILS • DIY 2015 <br /> too <br /> ONLY !.EG OIL PAJ&HAZ_p!u -USE USA605 FOR DIY"ANK ANJELICA 209 460 3925 REOUESTOR AN1:3ELICA ML3+&�2 <br /> Am 9 1 BLANKET PQ Pt 1063424.9 r <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> XNON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER. <br /> .,DESIGNATED TSDF: . ~ 0 <br /> ALTERNATE TSDF: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By si ng below 1 hereby cord ly that- <br /> (Waste oil generatoricustomer MUST check ONE of the following three boxes) <br /> have not mixed any of the waste described above with arty other hazardous waste,the total hallde Content is LESS than 1,000 ppm,and the waste does not conte[n 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 /> L]#21 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than i,Doo 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 43)This waste is from a tank which collects waste oil from household"do-ft-yourselt"(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 endlor CESOG sources.I have not mixed this wasle oil with any other hazardous waste or waste oil <br /> Irom other sources.I agree to accept the additional charges for disposal of this waste It the Informal Ion 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 plata to reduce the volume and taxi city of waste generated to the degree I have datermined to be ecpnom}ca€Iy prWEceb[e and that I have selected the <br /> pracl icable method of trealment,storage,or diapvsal currently oval robte to me which minimizes the present and future threa t to human Ilfe and the environment. <br /> This indkvlduai signing in the space set forth below on behalf of customer represents and warrants that helshe has the authorkty to bind customer,that lb 13:ongoing descriptions of waste <br /> and raaleriels are true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applkcatrfe state and federal regulations,and that customer shall abide <br /> by the Standard Terms and Condit[ons on the reverse slde of this Service Orgies. <br /> Service Orders with an associated hazardous Waste manifest(efther site specific or consolidated)are subject to an EPA Fee.These fees cover the EPA pass-through lee and administration <br /> of the aMankfasrvgram, These fees vary based on Martffest type. Applicable <br /> ?feesjwill appear on your hlflirrg Invoice. <br /> `Customer Signature Date ignature Date <br /> Print ams Print Driver Name <br /> I <br />