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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL, WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,,. <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H <br /> 1 1-800-727-2879 <br /> P <br /> E WWW.WORLDOILCORP.COM <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# JROUTE# jTRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 'LG <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> 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: _ <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 oil generator/customer MUST check ONE of the following three boxes) <br /> if#1)1 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 /> complied 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 /> Q #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 the waste does not contain 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 /> 0 #3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIV)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIV/CESOG collection tank is soley from DIV and/or 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 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 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 th apace sat forth below on behalf.1 custnmar represents and wo,ronls that holeh:has the authority to bind customer,that the[.,going descriptions of waste <br /> and,natarlels are t...nd accurate as packaged,marked.and Labeled.are ready for transportation in accordance with applicable state and tedaral regulations,and that customer shall abide <br /> by the Standard Terms antl Condition,on the fevers:side.1 this Sarvlce Ord- <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee.These I\.—r the EPA pass-through fee and administration <br /> of the:Manifest program.These fees vary based on Manifest type.Applicable fees will appear on your billing invoice, f <br /> Customer Signature Date Drip gnatur Date <br /> Print Name Print ver Name <br />