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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800.727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: C WORLDOIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,e <br /> S <br /> H 7300 CHEVRON WAY,DIXON,CA 95620 <br /> 1 1-800-727-2879 <br /> P <br /> E WWW.WORLDOILCORP.COM <br /> E <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 9 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASHREC'D: 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: — <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF. -- <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> d11)I 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 /> Compiled 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 /> Me 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 011 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 pmvlded 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(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIY/CESOG collection tank Is coley from Dry and/or CESOG sources.)he"not mixed this waste oil with any other hazardous waste or waste ell <br /> Irom 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. g <br /> This individual <br /> n the <br /> ace <br /> forth below on behalf of <br /> esents and warrants <br /> he/she has the <br /> to <br /> thatthe <br /> f waste <br /> and material.are true and accurate astpa packaged,marked,and labeled,are reedy/or transportation In at cordance with applicable stalte and federnd al regulationforgoing <br /> an d that customeions r$hall 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 pees-through fee and administration <br /> of the eManlfest program. These fees vary based on Manifest type. Applicable fees will appear on your billing Invoice. <br /> Customer Signature Date Driver Signature Date <br /> r <br /> Print Name Print Driver Name <br />