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FOR SEr,VICE CALL: SERVICE ORDER FORM NO. WOES004-B (8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES - <br /> g 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H 1-800-727-2879 <br /> P WWW.WORLDOILCORRCOM <br /> E TRANSPORTER EPA#CAD028277036 <br /> D <br /> T <br /> O <br /> CUSTOMER # PURCHASE ORDER # ROUTE# TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED HATE ENTERED NEXT SERVICE DATE CUSTOMER EPA#. BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION OTY UNIT PRICE OTY PIU TOTAL <br /> TOTAL <br /> CASH REC'D:_- GHECK# <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 that: <br /> (Waste ail generator/customer MUST check ONE of the following three boxes) <br /> Q #i)I have not 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 PCSS.1 have <br /> compiled with 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 11 <br /> the.information I have provided about this waste Is incorrect <br /> Q 421 have not mixed any ofthe waste described above with any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not confaln 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 /> Q #3)This waste is from a tank which collects waste oil from household"do-it-yourself"(131Y)and/or cosidltionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY!CESQG collection tank Is soley from DIY and/or CESOG sources.I have not mixed this waste all 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 /> (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 1 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 on behalf of customer represents and warrants that he/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 appticabie state and federal regulations,and that customer shat abide <br /> by the Standard Terms and Conditions on the reverse sWe of this Service Order, <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the eMani€est program. These tees vary based on Manifest type Applicable foes will appear on your bliihlg Invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />