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? SERVICE CALL: <br /> SERVICE ORDER FORM No. WOFSO4-8 (8/18) <br /> F?.. <br /> DIXON OFFICE ASSURY �NVI�4 MENTAL SERVICES, DBA SERVICE ORDER No. <br /> 1-800-727=2879 <br /> N3115022 <br /> FOR ACCOUNTING CALL: tn, WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES, <br /> s 7�Q�CHEVRON WAY, DIXONd CA 95620 <br /> 1 IMPERIAL TRUCK WASH AND REPAIR ,�AII 1-800-727-2679 2142 W YOSEMITE AVE <br /> r2142 W. YOSEMITE AVE WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 MANTECp, CA 135 7 <br /> MANTECA, CA 95337 1209) 239-81,11 <br /> (209) 239.8111 <br /> CUSTOMER# PURCHASE ORDER # ROUTE# TRUCK# MACIO Era S NDN E ORDER TAKEN BY HALIDES <br /> IMP072 CE-R8 8 <br /> ,RATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER E <br /> BILL of LADING/MANIFEST# <br /> 12124/201910,176 r <br /> BART# DESCRIPTION QTY UNIT PRICE OTY P/U TOTAL <br /> OFDR OIL FILTER DRUM REPLACEMENT - NO CHARGE 2 0. <br /> 2 $0-0� � $0.0(3 <br /> PF PAPER FILTERS PER DRUM ! $25,00 <br /> I <br /> EMS EMANIFESf EPA FEE & ADMIN - SITE SPECIFIC MAMFE T $25.tiQ <br /> FIAT 0 TOTAL <br /> CA$tN�REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> STATE.CODE 221 <br /> j.qN_8 jjA"AZAR.p,0V$WASTE,LIQUID(USER OILIMIXED OILS) STATE CODE <br /> r-,f�ON-RGRA 1-IAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) <br /> OTHER- <br /> DESIGNATED <br /> THER DESIGNATED TSDF: — <br /> ALTERNATE TSDF: -- Afsfs,xult Ml mWs Saul Rend <br /> ._G 7'r� OLD ACCT IMP067 <br /> DRUMS P 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 /> �} 01)1,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 Aho waste does not contain any Pegs.I have <br /> compiled with therequlrements bf the applicablo'Callfornla used all management rcgtilatfons to determine this is true.I agree to accept the additional charges for tho dispesal of this waste If <br /> the Infer mtitlpn 1 have pravidad about this wasfa is incorrect <br /> C2 I have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATE=R than 1,402 Ppm,and the waste docs not accconept <br /> any PCBs.F <br /> have provided proper documonlallon to World Oli Environmental Services to rebut the presunlPtion that this waste watt mixed with okhor hazardous waste.I agree to aceapt ttte additional <br /> charges for the disposal of this waste If the Information I have provided about this waste IS Incorrect <br /> (] C3)nia,waetu Is from a tank which collects wasto oil from household"do-IS-yoursWt^(qty)and/or conditionally exempt small quantity generator(CESaG)sourcoe.To the beat of my <br /> knowsdge,'tha'Only v7sstd'oil contained In my DlY/CESQG coilectlon tank is soiey from OfY and/or CESGG sources.I have not mixed this waste air with any other hazardous waste or Wawa all <br /> Irom fkar daiste ea.I agree to accapt tha additional charges for disposal of this vrasla if the intartnatlon I have provided abaurtttla weeny Is incorrect <br /> (All generators/Customers MUST.r6ad the following text <br /> 1 certify that I have o program In place to reduce the volume and toxicity of waste 9ener4tod to the degree t have determined to be economically practicable and that 1 have selected the <br /> practicable method of treatment.storage,or disposal currently available to me which minlmixes the present and future threat to human ills and the onvironmant- <br /> Title individual signing in the apace sat forth below on behalf of customer reprasenta and warrents that helahe has the,autharlty to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurate as packaged,marked,and labeled,are ready for transporistion In accordance w11h applicable state and federal reguiattons,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 assoclatod hazardous waste manifest(tither site sPociric or con Solldatod)are subject to an EPA Fee. TI7A fees cover the EPA pass-through fee and administration <br /> o1 the elVianlfest program. These fees vary based an Manifest type. Appllcable fees will appear on your billing Invoice. <br /> X C'r,---- - !Z �-Tf jZq. - 101711 Z?" <br /> custdrjer Signature Date Driv Signature <br /> 1/./ate <br /> t c. � <br />