Laserfiche WebLink
FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8118) <br /> DIXON OFFICE A BURY ENVIRONMENTAL SE VICES, DBS <br /> SERVICE 0RI�1 <br /> 1-800-727-287 4 NC. <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 It" WORLDOIL <br /> ENVIRONMENTAL SEIRVICES71.1 <br /> S 7300 CHEVRON WAY, DIXON.CA 956210 <br /> H <br /> 1-800-727-2879 <br /> f WW,WC3RI..DL31LCORP.COM <br /> D TRANSPORTER EPA#CA0028277036 <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE## TRUCK## CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATEENTERED NEXT SEROGEDATE CUSTOMER EPA a# BILL of LADING1 MAMFEST# <br /> PART## DESCRIPTION QTY UNIT PRICE JOTY PIU TOTAL <br /> f� <br /> ! TOTAL <br /> CASH RECD: CHEC; # <br /> WASTE DISPOSAL. INFORMATION <br /> 14ON-€iCRA HAZARDOUS WASTE, LIQUID(USED OIL/NII CED OILS) STATE CODE 221 <br /> {NON-MCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSI]F; <br /> ALTERNATE TSDF: <br /> DRUMS PIU: EMPTY DRUM& FACILITY; BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer FOU ST check ONE of the following three boxes) <br /> #1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is;-ESS than 1,000 ppm,and the waste does not contain any PCBs.I have <br /> complied with tate 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 /> the information I have provided about this waste is incorrect <br /> :1421 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.f <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this wastewas mixed with other hazardous waste.1 agree to accept the additional <br /> charges for the disposal of this waste It the information I have provided about this waste fir incorrect <br /> -D:3)This waste is from a tank which coilects waste oil from household"do-it-yourself"(f31Y)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 tram DIY and/or CESQG sources.I have not 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 /> (Ali generators/customers MUST read the following text <br /> 1 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 art behalf of customer represents and warrants that tre/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 shalt abide <br /> by the Standard Terms and Conditions on the reverse side of This Service Order. <br /> Service Orders with an associateci hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through tee and admimaraticn <br /> of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your Wiling invoice. . <br /> Customer Signature: Date Driver Signature Date: <br /> Print Name Print I3r"r Marne <br />