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FOR SERVICE CALL: # SERVICE ORDER FORM NO. WOES004-B (8/18) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER N0. 1-800-727-2679 FOR ACNG CALL: WORLD OIL 562-231-1550-1550 ENVIRONMENTAL SERVICES- 7300 CHEVRON WAY, DIXON,CA 95620 H TEC �iF .J1UF�iRlllsl - LC�LIISI: AVE 1-800a27-2679 P ,''OFnI ( LJUIS" %tVE WWW.WORLDOILCORP.COM 1) TRANSPORTER EPA#CAD028277036 0 1 Tf 2 LAI HROP C;A 982} i0 1 209) 868-411 L'I CUSTOMER# PURCHASE ORDER# ROUTE# I TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# PART# DESCRIPTION QTY UNIT PRICE TY P/ U TOTAL 6C TOTAL CASH REC'D: CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE_ OTHER: DESIGNATED TSDF: ASBURY EWIlRCtdMENTAL SERVICES CERES, 1320 MORGAN RD C:ERE.S ;lA +.IBM C41.0/303y:YiRll ALTERNATE TSDF: Accowx 73ana2er Sam Hetet DRUMS P/U: EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) By signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) #1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS then i,D00 ppm,and the waste does not contain any PCBs.I have 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 the Information I have provided about this waste Is Incorrect 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 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 charges for the disposal of this waste If the Information I have provided about this waste is Incorrect 0 #3)This 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 knowledge,the only waste oil contained In my DIY/CESOG collection tank Is coley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil 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 (All generators/customers MUST read the following text I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the dog me I have determined to be economically practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human IIle and the environment. This Individual signing In the apace set forth below on behalf of customer represents and warrants that he/she hes the authority to and customer,that the forgoing descriptions of waste and materials are true and accurate as packaged,marked,and labeled,are ready for transportation In accordance with applicable stale and federal regulations,and that customer shall abide by the Standard Terms and Conditions on the reverse Side of this Service Order. Seryica,Qrders with an associated hazardous waste manifest(either site&pacific or consolidated)are subiect to an EPA Fee.-These fees cover the EPA pass-through fee and administration Of a eM,nlfest ogram. These Jess vary based on Manifest type. Applicable fees will appear on your b1 ling Invoice. f t A J� Custom ignature net. Driver Signature Date ?r 7� �'G Z 3 ✓✓f to) F Print Name Print Driver Name