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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B (8/18) <br /> DIXON OFFICE ;ASBURY ENVIRONMENTAL SERVICES, DB,A SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: <br /> WORLD OIL <br /> 562-231-1550 <br /> to . <br /> ENVIRONMENTAL SERVICES,. <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H 1-800-727-2879 <br /> P <br /> P WWW.WORLDOILCORRCOM <br /> E TRANSPORTER EPA#CAD028277036 <br /> T v `t <br /> O „ <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATELL� CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE CITY P/U TOTAL <br /> ..�, ,.i.. r wi .?..i n.-.iit '^�... � - b <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OlUMIXED OILS) STATE CODE 221 <br /> NON-RCRA'HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER. .,. <br /> DESIGNATED TSDF. <br /> ALTERNATE TSDF: <br /> f <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE SOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/Customer MUST check ONE of the following throe boxes) <br /> Q #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 oftheapplicable 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 /> Q #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.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/or CESQG sources.I have riot 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 /> 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 descriptions of 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 program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Driver Signature Date <br /> Customer Signature Date <br /> y ,' <br />