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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES,DBA FORM NO.WOES004-B (4/17) <br /> 1-800-727-2879 � SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: <br /> 562-231-1550 <br /> WORLD OIL <br /> ENVIRONMENTAL SERVICES- <br /> s <br /> H 7300 CHEVRON WAY,DIXON CA 95620 <br /> I 1-800-727-2879 <br /> P <br /> E WWW.WORLDOILCORP.COM <br /> D <br /> T TRANSPORTER EPA#CAD028277036 <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# I TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART 4 DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: 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 TSOF: <br /> ALTERNATETSDF: <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 /> O#1)I have-ot mixed any of the waste described above with any other hazardaus waste,the total halide content is LESS than 1,000 ppm,and the waste does not contain any PCB&I have complied with the requirements of <br /> the applicable CalFornia used oil management regulations to determine this is true.I agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is incorrect <br /> O#21 have not mixed any of the waste descrited abcve with any other hazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCs,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 charges for the disposal of this <br /> waste if the information I have provided about this waste is incorrect <br /> 0#--I This wane isfrom atank which collects waste it from h—whald'do-it-yourself(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.Tothe best of my knowledge,the only waste oil contained <br /> nmy DIY/CESQG zzllectian tank is coley from DIY and/or CESQG sources.I have not mixed this waste it with any other hazardous waste or waste oil from other sources.I agree m accept the additional charges for disposal <br /> of ttis waste If the idormation I have provides about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> =#z)If I am a large quantity generator,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 <br /> selected the practizeble method of treatment,storage,or disposal currently available tome which minimizes the present and future threat to human life and the environment Or,if I am a small quantity generator,I <br /> hale made a good faith effort to minimize my waste generation and select the best waste management method that is available tome that I can afford, <br /> This individual sigri,g in the space set forth telow m behalf of Customer represents and warrants that he/she has the authority to bind Customer,that the forgoing descriptions of waste and materials are true and accurate <br /> as packaged marked and labeled,are ready for transportation 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 /> side of this Service Order. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />