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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: WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,, <br /> H 'rI.OF CA.LIi=OR!`.I f''.. -.�:ul.al_. %\V; 7300 CHEVRON WAY,DIXON,CA 95620 <br /> rr 1-800-727-2879 <br /> p _051 [ ,...C:,!i:;ii AVIS �nc,0 LOUI.SE A.V'E <br /> p WWW.WORLDOILCORRCOM <br /> T 1 T­4;T!:�0P,CA 953?0 TRANSPORTER EPA#CAD028277036 LATFiROP CA 95330 <br /> o <br /> CUSTOMER# PURCHASE ORDER# ROUTE# I TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 1 /rt 0 L� Gcri-013 070 <br /> /Z/ iPN •" <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> i'114/1019 ?0/.?92019 CAL0004771,70 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> V` l.! _.U ;VILIALUILAI�UGA; ULIN�� FIL!-ZRS _ TSE.cc r1?C.00 <br /> OFDR OIL KILTER DRUfVI REPLACEMENT- NO CHARGE > $0,0C 2 SC.00 <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE_ <br /> OTHER: - ..f_.0 1.H,,;r,:%NT Pdlydr. -t. I --'^T- <br /> DESIGNATED TSDF: 'f ES iPs,:wiGEJc1:T, IidC.,1500 i.S RIGhINAY 95,'/UiJA,AZ 85365,928-3�A-5625 <br /> ALTERNATE TSDF: <br /> ::/os� Account Manager: Sam Read <br /> tp <br /> DRUMS P EMPTY DRUMS: FACILITY: BSC I "�`� <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIfi!ATE d6X)j j <br /> SY signing below 1 hereby cantly that: I'�I <br /> (Waste oil generator/customer MUST check ONE of the following th're _ <br /> eboxes) ( ' <br /> Q a1)1 have not mixed any of the weals described above with any other hazardous waste,Ne total halide content Is LESS than 7,000 ppm,alai Ne waste does nR conIxm-eey.P.C9s.I have <br /> compiled with the requirements of the applicable California used all management regulations to determine this is true.I agree to accept Me Additional charges forfie dispo8elofth'Is.-mef`1f t <br /> the Inlormetlon I have provided about this waste Is Incorrect <br /> 0 021 have not mixed any of the waste described above with any other hazardoub waste,the total halide Cement Is GREATER than 1,000 ppm,and the waste does not contain any PCBs.l <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.l agree to accept the additional <br /> charges for the disposal of this waste it the inlormatlon f have provltled about this waste Is Incorrect <br /> 0 93)This waste Is from a tank which collects waste oil from household"do-it-yourself"(DIY)anNor conditionally exempt small quantity generator(CESOG)sourcee.To the beet of my <br /> knowlodge,the only waste all contained In my DIY/CESOG collection tank is salary from OIY and/or CESOG sources.I have not mixed this waste oil with any other hazmdous 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 le Incorrect <br /> (All generators/customers MUST read the following text <br /> 1 canny Met l he"a program In place to reduce the volume and toxicity of waste generated to We degree I have determined to be economically practicable and that I have selected me <br /> pracllcable method of treatment,storage,or disposal currently evallable to me which minimizes me present and future threat to human life and the environment. <br /> This Individual signing In the space sat form below on behalf of customer represents and warrants that helshe has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials em Mme and accurate as pack ad 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 revame side of this Service Order. <br /> Service Ord re with en eesocI ted hazardous waste manifest(either site specific or consolidated)we sub=to an EPA Fes. These fees cover the EPA passthrough fee and administration <br /> of the eMe sal program. Th e lees very basetl on 1.nlfasl type.Applicable fees will appear on your billing lnvolC <br /> bust6 re Date Driver Signature J 1Date <br /> Print Name Print Driver Name <br />