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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8118) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SE=RVICE ORDER NO. 1.800-727-2879 FOR ACCOUNTI NG CALI_: 7 9_231-1550 =f WORLD OIL ENVIRONMENTAL SERVICES-t, 5 7300 CHEVRON WAY,DIXON, CA 95620 " LKS AUTO PARTS- 1-800-727-2879 RE[)DING AUTO CENTCR LKQ - R P YsA1 I`IA.`'Y URIVE WWW.WORLDOILCORP.COM 2851 VIVJNC=1WAY E TRANSPORTER EPA#CAD028277036 g5 I UL11IJ1 s, C;�� isilit,t r 1 0389-@ SZVC -' 31 .► -'h'1�3 f CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES , 1Ldt=YV:A-TH 4C fc r S�:H :ULkLfzl i DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADINW MANIFEST# C: L tui, j •,r! %, (" (. w i PART# DESCRIPTION QTY UNIT PRICE QTY P/Uj TOTAL (c; �_slci� j ,--i_i r:..,.t�3•.�.s�5-4$a�t TOTAL SH CASH RECD: CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED O1LIMIXED OILS) STATE CODE 221 NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATED TSDF: - - „, � w,r, a 8G ALTERNATE TSDF: DRUMS PIU: EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) By signing below I hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) r j}'11)I have not mixed any of the waste described above with any other hazardous waste,the total betide content is LESS than 1A110 ppm,and the waste does not contain any PCBs.!have complied with the requirements of the applicable California used oil management regulations to determine this Is true.i agree to accept the additlonal charges for the disposal of this waste if the information 1 have provided about this waste Is incorrect Q 92 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1,060 ppm,and the waste does not contain any PCBs.I 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 waste if the information I have provided about this waste Is incorrect 0 A3)This waste is from a tank which collects waste oil from household"do-It-yourself`(DIY)andlnr conditionally exempt small quantity generator(CESQG)sources.To the hest of my knowledge,the only waste oil contained In my DIY/CESCG collection tank is Soley from DIY andror CESQG sources.l have not mixed this waste oil with any other hazardous waste or waste all 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 (All generators/customers MUST read the following text I certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree l have determined to be economically practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and the environment. This Indlvtdual signing in the space set forth below on behalf of customer represents and warrants that heJshe has the authority to bind customer,that tho forgoing descriptions of waste and malerIsis are live and acpurole as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations,and mat customer shall abtdo /by the Standard Terms and Conditions on the roverso side of this Service Order. ( �ICB Ortlasy with in aa/aelatpd hezYfdoua waste mnnifoat(either site specific or consolidated)are subject to an EPA Fce. These flees cOvrr the EPA pass-through!q6 ertd adnalnistralion yyry omanlfpt proofs-;The"fow vary based on Mantled type. Applicable fees will appear an your bitting invoice. r Signature '(61IIStafher �! � 1 Driver Signature _-------.__-- [3 ate Print Name Print lOr4ver Name