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FOPS.ERVICE CALL: SE-R V I CE ORDER FORM NO. WOES004-B(8118) <br /> DIXON OFFICE ASSURE' Es ViRONME TAL SERVICES, DBA SERVICE ORDER SIO. <br /> 'I-888-727-2879 <br /> Q <br /> FOR ACCOUNTING CALL: �C) y - -- ------� <br /> 562-231-1550 WORLD <br /> ENVIRONMENTAL SERVICES- <br /> 7300 00 CHEVRON WAY, DIXON,CA 95624 <br /> 1-800-727-2879 <br /> D TRANSPORTER EPA#CAD028277036 <br /> Tr_.. .. <br /> CUSTOMER# PURCHASE ORDER# qOUTE# TRUC # CONTACT NAPAE ORDER TAKEN BY HALIDE <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE r".ATE CUSTOMER EPA# BILL of LADINGI MANIFEST# <br /> PART# DESCRIPTION OT UNIT PRICE OTY P/U. TOTAL <br /> S <br /> Ii <br /> TOTAL. <br /> CASH PEC'D: CHECK# <br /> WASSTE DISPOSAL INFO RNIATIONI <br /> ° NON-RGRA HAZARDOUS WASTE, LIQUID(USED€ lUllifiIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE___ <br /> 01-ICER: - <br /> DESIGNATED TSDF. � <br /> . <br /> ALTERNATE TSDF: <br /> DRL.MS PIU: tl_ EMPTY DI�IJI�t�iS: FACILITY:.. - �BSC <br /> - <br /> DRUMS <br /> GENERAITOR WASTE CERTIFICATION (PLEAS CHECK-THE APPROP'RIAT'E BOX) <br /> 9y sighing below I hereby certify that: <br /> (Waste rail generator/cu t r er MUST check ONE of the following three boxes) <br /> I have not mixed any pf the waste described above with any other hazardous waste,the tetai halide content is LESS than 1,00tl ppm,and the waste does not contain any PCBs.I have <br /> complied with the requirements of the applicable Caiitornia used all management regulations to determine this is true.I agree to accept the additional-charges for the disposal of this waste if <br /> tiie information i Soave provided about ttds waste is incorrect <br /> iJ U€have not mixed any of the waste described above with any other hazardous waste,the totel halide content is GREATER than 1,00€1 ppm,and the waste does not contain any FCRS-i <br /> have provided proper documantation to Worfd Oil Environmantal Services to rebut the presumption that this wasto was mixed with other haaardous waste.i agree to accept the additfonai <br /> charges for the disposal of this waste it the information l have pravided about this waste is incorrev, <br /> J 43)This waste is from a tank which collects Waste oil from household"do-it-yourself"(ow)and){sr condittonatty exempt small quantity generator(CE$QG)sources.To the best of my <br /> imow€edge,the only wasis oil contained in my DIY)CESOG collection tank Is soEey from DTY anWnr Cl=SQG sources.I have not mixed this waste oil with any other hazardous waste or waste oi! <br /> from other sources.I agree to accept the additi©nal charges for disposal of this waste if the Information I have provided about this Waste is incorrect <br /> (All generators/custorners MUST read the following text <br /> 1 certify that I have a.program in place to reduce the volume find toxicity of waste generated to the degree I have determined to be economically practirabie and that f have selected the <br /> practicable method of treatment,storage,or disposaZ currently avalfable to me which minimizes the present and future threat to human Me and the environment. <br /> This individual sighing inthespace set terth below an behalf of customer represents and warrants that helshe has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurate as packaged,marlted,and labeled,are ready for transportation in accordance with appficabte state and federal regu€aborts,and that customer shati abide <br /> vy the Standard Terms and Conditions on the reverse side of this Service Order. <br /> Service Orders with a associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through tee and administration <br /> of the LMartifest pro ram. These teas vary based on Manifest type. Applicable fees t'vili appear on your billing invoice. <br /> // 712-.0 , 1l7 <br /> C�€stom 'Si ature Int Driver Signature Data <br /> Print Na Print Driver Name <br />