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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 /> 582-231-1550 <br /> ENVIRONMENTAL- SERVICES,�� <br /> 9 <br /> H7300 CHEVRON WAY,DIXON,CA 95620 <br /> -800-727-2879 <br /> P <br /> E WWW.WORLDOILCORRCOM <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> O <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# DESCRIPTION QTY UNIT PEACE QTY PIU TOTAL <br /> CASH REC'D: — CHECK# TOTAL <br /> WASTE DISPOSAL INFORMATION <br /> NON-MCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> _— <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 I hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 rnpnad with the requirementof s ofvthetapplliicabe Cnifforniave lth any used oilther linardous waste,management regulati ns to total <br /> deterrmiinnecontent <br /> true.I agree to accep the addit n al Ppm,and the c adoes not rges for the s€posal or this aste if <br /> the Information I have provided about this waste€s incorrect <br /> 0 #2 1 have not mixed any of the waste descr€bed 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 agres to accept the additional <br /> Charges for the disposal of this waste if the information I have provided about this waste is Incorrect <br /> u 03)This waste is from a tank which collects waste o11 from household"do-it-yourself'(DIY)andfor conduionaliy exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIY/CESOG collection tank Is soley from DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.1 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 ava112b1e to me which minimizos the present and future threat to human life and the environment. <br /> This individual signing In the space set forth below on behalf of customer represents and warrants that he/she has the authority to bind customer,that the forgoing descriptions of waste <br /> and materlaia are true and accurate as packaged-marked,and labeled.are ready for transportation in accordance with applicable state and federal <br /> regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse aide of this Service Order. <br /> service orders with an associated hazardous waste manifest(either site specific or consolidated)aro subject to an EPA Eee, These fees cover the EPA <br /> Pass-through fee and administration <br /> of the etllanifest program. These fees vary based on Manifest type, Applicable fees will appear on your bailing invoice. <br /> Customer Signature — Date — / / <br /> Driver Signature Date <br /> Print Name — -----� — _ — T _ _Driv <br /> Print er Name — ---- <br />