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FORSEP"10-E Ill SEF'VICE ORDER <br /> DIXON OFFICE SBURY ENVIRONMENTAL SERVICES, DBA FORM NO-WOES004-B <br /> 1-800-7-ASOURY <br /> SERVICE ORDER NO. <br /> PARLIER <br /> 559-498-0240 <br /> CHICO <br /> 800-733-9043 WORLD OIL <br /> 5EWRONMENTAL SERVICEST.= <br /> H <br /> 1300 SOUTH SANTA FE,COMPTON CA 90221 <br /> PP RH-Oj!D"!' -C)URT LOS ANGELES,OFFICE <br /> 1-800-974-4495 <br /> ',NA� <br /> TRANSPORTER EPA#CAD028272036 <br /> CUSTOMER# PURCHASE ORDER# ROUTF4 TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> j <br /> DATE REQUIRED DATEENTEREDNEXT SERVICE DATE CUSTOMER EPA ft' BILL of LADING/MAl# <br /> PART# DESCRIPTION <br /> QTY UNIT PRICE QTY P/U TOTAL <br /> USED OIL I Nil Ciii_ <br /> so,cc) <br /> o <br /> RFT"'Pi A <br /> 44 1 <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIl OILS) STATE CODE 22T <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATEDTSDF: <br /> HALTERNATETSDF: <br /> DRUMS P/U:_ EMPTY DRUMS:— FACILITY:— BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECKTHE APPROPRIATE BOX) <br /> By signing below I hereby certify that. <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 l and the waste does not contain any"Cill I have complied with the requirements of <br /> the applicable California used oil management regulations to determine this is true.I agree to accept the additional charges for the disposal ofth[s waste if the information I have provided aboutthis waste is incorrect <br /> =3#2 1 have not mixed any of the waste described above with any other hazardous waste,rhe total halide correnT is GREATER than 11=00l and the waste does not contain any PCBs.I <br /> have provided proper documentation to Word Oil Environmental Services to rebut the presumption that thlr;waste was mixed with other hazardous waste.i agree to accept the additional charges for The disposal of this <br /> waste if the informazion I have provided about this waste 151incorrect <br /> =#3)This waste is from a tank which collects waste oil from hau5ehold'do-lt-y"rself"(DIV)and/or conditionally exempt small quantity generator[CFSQCi)sources.To the best of my knowledge,the only waste oil contained <br /> in My Dly/CES46 collection tank is Soley from DIY an(i CESOG sources-I have not mixed this waste Oil with any other hazardous waste or WdAE Oil from other Mirces.I agree to accept the additional chargesfur disposal <br /> Of this waste if the information J have provided about this waste is Incorrect <br /> (All generators/customers MUST read the following text and check the associated box,) <br /> 1504)if I am a large quantity generator,I certify that I have a program in pia,,e to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicalkfe and that I have <br /> selected the practicable method of treat-ent,storage,or disposal currently available to me which minimizes the present and future threat to human fife and the environment;Or,if I am a small quarriltyge9wrator,I <br /> have made a good faith effort to rninimize my waste generation and select the best waste maragerrent method that is available W me that I can affGrni <br /> This individual signing in the space set forth below on behalf of Customer represents and warrants that helshe has the authority to bind CUSTOMM,that the forgoing descriptions of waste and materials are true and accurate <br /> as packaged,marked and labeled,are ready for cranspol in accordance with applicable state and federal regulations,and that Customer shall abide and be bound by the Standard Terms and Conditions on the reverse <br /> 'doof this Service Oicejr. <br /> C tomer Sliqn�ture <br /> Date Driver 5 mature <br /> Date <br /> Print Name <br /> Print Drivers <br /> Name <br />