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Frig SERVICE CALL: SERVICE ORDER FORM NO. WOES004-13 (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2878 SERVICE ORDER NO. <br /> FOR ACCOUNTING GALL: WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES_ <br /> 5 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H 1-806-727.2879 <br /> I <br /> WWW.WORLDOILCORP.COM <br /> D TRANSPORTER EPA#CAD028277036 <br /> 0 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION OTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIUMIXED 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 PIU: 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 /> #1)t have riot 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 wnli 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 /> the Information I have provided about this waste is incorrect <br /> 0 #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 Oil 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 provided about this waste Is Incorrect <br /> 0 #3)This waste Is from a lank which collects waste all from household"do-it-yourself"(OIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY!CESOG collection tank is coley from OIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste aid <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 /> (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 rrilnimizes the present and future threat to human tile and the environment. <br /> This Individual signing in the space set forth below on behalf of customer represents and warrents that helshe 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 shall 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 art EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the eManifest progrartl, These fees vary based on Manifest type. Applicable fees win appear on your billing Invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />