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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA FORM NO. WOES004-B(8/18) <br /> 1-800-727-2879 SERVICE ORDER NO, <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 wO R L Q O I L <br /> ENVIRONMENTAL SERVICES- <br /> „H 7300 CHEVRON WAY, DIXON. CA 95620 <br /> P 1-800-727-2879 <br /> E WWW.WORLDOILCORP.COM <br /> ° TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <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 QTY UNIT PRICE OTY PIU TOTAL <br /> TOTAL <br /> CASH RECD: 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 than <br /> �1 (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> u #1)f have not mixed any o1 the waste described above with any other hazardous waste,the total halide content Is LESS than 1,000 ppm,and he waste does not contain any PCBs.I have <br /> ct)mplled with the requirements of the applicable California used oil management regulations to determine this is true,1 agree to accept the additional charges for the dlsposai of this waste if <br /> the information 1 have provided about this waste Is incorreci <br /> p #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 he waste does not contain any PCBs.I <br /> have provided proper documentation to World Oil Environmental services to rebut the presumption that Ibis waste was mixed wifh 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 /> waste Oil from <br /> do <br /> ld <br /> kn wiedge he only waste off Cote <br /> ntained inch <br /> tmysDIY/CESQG collection tank s soleyufrom oIYly)andfor and/or CESOGIslourrcl s.I'laveexempt <br /> amixed this waste oi)with any other hazardous waste or waste oil <br /> om other sources.1 agree to accept the additional charges for disposal of This waste if the information I have provided about this waste IS incorrect <br /> {CE54G)sources.To he hest of my <br /> (All generators/customers MUST read the following <br /> e <br /> 1 certify that i have a program in place to reduce the volume and toxicity a1 Waste generated to the degree 1 have determined to be economically prach able and that f have selected the <br /> practicabie method of treatment,storage.or disposal currently avallabre to me which infnimizes the present and future threat to human)lfe and the environment. <br /> This individual signing In the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgoing descriptions at waste <br /> and a Standard <br /> are true and Conditions <br /> as packaged,marked,and labeled,are reedy for fransportaton In accordance with applicable state and federal reputations,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 aSSOClated hazardous waste manifest(either site specific or consolidated)are sub to an EPA Fee. These fees cover the EPA pass-through fee and adminislration <br /> of the eManifest program. These fees vary based an Manifest type. Applicable fees Will appear on your bjiling Invoice. <br /> �lstomer Signa / - f <br /> Date <br /> ` Driver Signature Date <br /> t Name <br /> Print Driver Name �~ <br />