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FOA SERVICE CALL: SERVICE ORDER FORM NO. WOES004-13(8118) <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 <br /> H 7300 CHEVRON WAY. DIXON.CA 95620 <br /> 1 1-80(1-727-2879 <br /> P <br /> E WWW.WORLDOILCORP.COM <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <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 /> CASH RECD: CHECK# TOTAL <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIIJWXED 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 PN: EMPTY DRUMS: _ FACILITY:_ BSC - - -- - - <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below 1 hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> s11 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 PCSs.I have <br /> compiled with the requirements of the applicable California used oil management regulations to agree t <br /> 1 a <br /> . go accept the additional charges for the <br /> the irrformatfoh I have provided about this waste is incorrect determine this is tropge disposal of this waste If <br /> U 02 1 have riot 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 documents tion to world Otl 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 /> E 03)This wast*is from a tank which coflects waste 011 from household•(10-it-yourself"(DIY)and/or conditionally exempt small quantity generator ICESOCa)sources.To the best of my <br /> from <br /> other the only wast*oil contained in m!DIY/CESGIG collection tank is snley Iron bry and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste dl <br /> from other sources.I agree 147 accept the addttlonal charges for disposal of this waste it the Information r have provided about this waste is Incorrect <br /> (All generators/customers MUST read the fallowing 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 mahod of treatment,Storage,of disposal currently available to me which minimizes the present and future threat to human life and the environment. <br /> This Individual slpdng in the space set forth below on behalf of customer <br /> and materials Me true and acetlraip is packaged.marked,end labeled,are readyfor trans end warrants that helshe has the authority to bind customer,that the forgoing descriptions of waste <br /> by the Standard Terms and Conditions on the reverse side of this Service Order. ePD��in accordance with applicable state end tederN regulations.and that customer shall abide <br /> Service Madera with r m. The f hazardous waste manifest(either site specific or consolidated)ere subiect to an EPA roe. These fees cover the EPA pass-through fee and administration <br /> of the amtsnftast program. '[these fees vary based on Usnffeat typ*, Applicable fees will appear on your billing invoice. <br /> / JI <br /> Customer Signature Date <br /> Driver Signature Date <br /> Print Name <br /> Print Driver Name <br />