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OR SERVICE CALL: SERVI-Ge ORDER FORM NO.WOE5004-13 (8/18) <br /> DIXON OFFICE,,` <br /> FFICE .. ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 9 s SERVICE ORDER'NO. <br /> 1-8O0-727-287 <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 CWORLDOIL <br /> ENVIRONMENTAL SERVICESr <br /> s 7300 CHEVRON WAY,DIXON,CA 95620 <br /> jl ,- 1-800-727-2879 <br /> Ba� <br /> P UJWW.UVORLDOILCORP.COM <br /> D TRANSPORTER EPA#CAD028277036 <br /> T t <br /> , <br /> .j~ <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATEREQUIRED DATE ENTERED NEXT_SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT.PRICE QTY PIU TOTAL <br /> <. s� N x <br /> TOTAL <br /> CASH'R'EC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS.WASTE,.LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> MON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: - <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> DRUMS P/U., �,E°'� .� EMPTY DRUMS: FACILITY: SSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> IS signing below t hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Q #1)fhave 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 1 have.provided.about:this waste is incorrect <br /> Q #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 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 /> 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(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is soley from DIY and/orCESQG sources.I have not mixed thiswaste 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 descriptionsof 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 , ram. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Dye <br /> Thin$ Pi- Drini 17) h-Name <br />