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z _ <br /> ERVICE CALL: "','SERVICE ORDER FORM NO. WOES,Q04-B (8/18) ; <br /> OFFICc,;, AS URY ENVIRONMENTA SERVI ES, IDSA 1 99 <br /> 727-2878 SERVICE ORDER't�lO. <br /> , <br /> ,CCOUNTING CALL: <br /> 31-1550 MORLD OIL„ <br /> ENVIRONMENTAL SERVICES- <br /> I <br /> 7300 CHEVRON WAY, DIXON,CA 95620 1 <br /> 1-800-727-2879 <br /> WWW.WORLDOILCORP.COM <br /> TRANSPORTER EPA#CAD028277036 <br /> 'OMER # PURCHASE ORDER # ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 3EQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> I <br /> T# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> a <br /> „3 <br /> I � <br /> I <br /> TOTAL I <br /> I REC'D: CHECK# � <br /> WASTE DISPOSAL INFORMATION m....; <br /> ON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> M <br /> ON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> )THER: — — — o <br /> ESIGNATED TSDF: X: <br /> LTERNATE TSDF: ° <br /> IS P/U EMPTY DRUMS: FACILITY: BSC <br /> i <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> ing below i hereby certify that: <br /> (Waste oil generatorfcustomer MUST check ONE of the following three boxes) i <br /> i ” <br /> 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 PC8s.I have <br /> �d 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 /> rmation I have provided about this waste is incorrect - <br /> have not mixed any of the waste described abovewith any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> ovided 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 /> i for the disposal of this waste if the information I have provided about this waste is incorrect <br /> rhis 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 f <br /> dge,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 /> her sources.I agree to accept the additional charges for disposal of this waste if the information I have provided about this waste is incorrect f <br /> ( <br /> (All generators/customers MUST read the following text � <br /> 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 /> rble method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. <br /> iivldual 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 /> terials 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 /> Randard Terms and Conditions on the reverse side of this Service Order. <br /> 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 /> Manifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. I <br /> r I <br /> / <br /> :)mer Signature Date Driver Signature Date <br /> I tI I <br /> Name – — - -- Print Driver Name � <br />