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yOSERVICE CALL: SERVICE ORDER FORM NO.WOE.SO04-B(81 <br /> DIXON OFFICE ASBURY E VIRONI ENTA SERVICES, DBA SERVICE ORD" NQ. <br /> 1-80-727-2879 <br /> p <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 "WORLD OIL <br /> ENVIRONMENTAL SERVICES,,, <br /> 5 ._ 730,0>CHFVPON WAY, DIXON,CA 95620 � <br /> H 1-800-727-2879 <br /> WWW. ORLDOiLCORP.CO B <br /> D <br /> G TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <br /> CUSTOMER#b PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDE! <br /> s <br /> DATE REQ It EO DATE ENTERED NEXT SERVICE DATE CUSTOMER EFTA# S3LL[e#LADING/MANIFEST# <br /> PART# DESCRIPTION QTY -UNIT PRICE QTY illi TOTAL <br /> TOTAL <br /> CASH RECD- CHECK# <br /> WASTE DISPOSAL IMFORMAT@CN <br /> NON-RCRA HAZARDOUS TASTE.LIQUID(USED OILIMIXED OILS) S'K'ATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TDF; — <br /> ALTERNATE TSDF: <br /> DRUMS Pili:' EMPTY DRUMS: FACILITY: - BSC <br /> GENERATOR WASTE CERTIFICATION(PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing belcvt#hereby certify that: <br /> (Waste nil generatorlcustcraer MIDST check ONE of the following three ores) <br /> fit)i have not mixed any of the waste described above with any other hazardous waste.the total bar#de content is LESS than i,000 ppm,and the waste does not contain any,pCffs.I have <br /> complied with the requirements of the applicable California used.oil management regulations to determine ibis is true.t agree to accept the additional charges for the disposal of this waste d <br /> the information i have provided aksout this waste is incorrect <br /> 0;2#have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1,ao6 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to World OiI Enviranmemai 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 /> D K8)This waste is from a tanK which collects waste oil From household"do-it-yourself'(DIY)andlor conditionally exempt small quantity generator(GESGG)sources.To the best of my <br /> knowledge,the only haste oil contained in my OIYI CESUG collection tank is soiey from DIY andlor CcSOG sources.1 have not mixed this waste oil with any ether hazardous waste or waste a <br /> from other saurces.I agree to accept the additional charges for disposal of this waste if the intarmatiori I have provided about this waste is incorrect <br /> (All generatorsi customers MUST read the following text <br /> €certify that[have a program in place to reduce the volurne 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 lite and the environment. <br /> This individvai signing-in the space set forth below on behalf of customer represents andwarrants that helshe has the authority' 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 shah abtda <br /> - - by the Standard Terms and Conditions on the reverse side of ibis Service Order. - <br /> Service Orders wlth an associated hazardous waste manifest(either site spaatftc or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the eManffesf program.Thee fees vary based on PAanifesi type. Applicable fees will appear an your billing invoice. <br /> Customer Signature mate Driver Signature Date <br /> Print Name Print Critter Name <br />