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FOR SERVICE CALL_ SERVICE ORDER FORM NO. WOES004-8(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: Ba a, N321589P <br /> 562-231-1550 " WORLD O I L <br /> ENVIRONMENTAL SERVICES,. <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> " IMPERIAL TRUCK\iVASH AND REPAIR JAZZ 1-800-727-2879 <br /> P 2142 W. YOSEMITE AVE 2142 W. YOSEMITE AVE <br /> P WWW.WORLDOILCORP.COM <br /> D TRANSPORTER EPA#CAD028277036 <br /> T MANTECA, CA 95337 MAN T ECA, CA 9537 <br /> 0 09) 39-811 ! (209) 239-81; <br /> CUSTOMER# PURCHASE ORDER # ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> iMP072 CER-86 � r,rANJE I SING;I <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> d If;1202C <br /> CA 0003686g3 II [� <br /> U 1 V c� �- <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PJU TOTAL <br /> PF PAPER FILTERS PER bFiiJf,l $85.OG $170.00 <br /> OFDR Oil- FILTER DRUM REPLACEMENT - CEO CHARGE _ $0.00 $0.00 <br /> f=: ------- TOTAL <br /> CASH REC'D: 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: I lrO=R,n f—Ir ., TG." <br /> DESIGNATED TSDF: •" irf hid vrLvr,Ur ,NC. 53U IIS irk I':1L'AY 95. '�Jh r /,",35355 <br /> ALTERNATE TSDF: <br /> ;DI._i AC.rrl7 Iii <br /> DRUMS P/U:__�_ ^ EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) } t. <br /> By signing below I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the tollowing thr!pboxesy--- - f <br /> ❑#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 PCBs.I 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 if <br /> the Information I have provided about this waste is incorrect <br /> I,.J#2 I 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 Environmenlal Services to rebut the presumption that this waste was miKed with other hazardous waste.I agree to accept the addltionat <br /> charges for the disposal of this waste It the information I have provided about this waste Is incorrect <br /> Z)#3)This waste is from a tank which collects waste oil from household"do-it-yourself"(DlY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY!CESOG collection tank is soley from DIY ancifor CESOG 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 t 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 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 hind 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 aciated 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 eManif rogr ii- These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> 09 1-�I l - I f k _. <br /> Customer§ign u e Date Driver Signature D to <br /> l I (A <br /> Print Name) Print Driver Name <br />