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FOR SERVICE CALL: SERVICE ORDER DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES DBA FORM N©.VVOESgg4-S(8118) 1-8010-727-2879 SERVICE SERVICE ORDER NO. FOR ACCpUNTING CALL- � WORLD OIL 29i-1550 ENVIRONMENTAL SERVICES- S 7300 CHEVRON WAY.DIXON,CA 95620 " LKQ AUT`,0 DART:, LW-K- 1-800-727-2879 Rl`I UIF•IG ALIT C)CENTER LKQ- R E41 f lA>!�`i3lI',:I www.woRLDOILcoRP.cOM #5U VI40i,#+��+IAy' D TRANSPORTER EPA#CAD028277036 T ST CK1-Qi'J CA n J2od REDIUII-I1:3.CA 913003 ° ( 0 )689.1619, 1(53Ul 35d-1218 CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES k- : DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# PART# DESCRIPTION QTY UNIT PRICE QTY IP/U TOTAL I"fH VLf_NE 31'P'..:�4.SOLU11011S I ]rye! TOTAL CASH REC'D: CHECK# WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE CODE.221 NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE OTHER: DESIGNATED TSDF: - ALTERNATE TSDF: DRUMS PIU: EMPTY DRUMS: FACILITY: BSG 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) #1)t have not mixed any of the waste described above with any other hazardous waste,the total halide content Is LESS than i mo ppm,and the waste does not contain any PCBs.I have compiled 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 the Information I have provided about this waste Is incorrect a #2 t 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 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 addlilonal charges for the disposal of this waste if the Information I have provided about this waste is Incorrect 0 #3)This waste Is from a tank which eolteets waste oil from household"do-It-yourself"(DIY)andlor conditionally exempt small quantity generator(CESQG)sources.To the best of my knowledge,the only waste oil contained in my DIYI CESQG collection tank is coley from DIY andlor CESQG sources,i have not mixed this waste all with any other hazardous waste or waste oil 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 (Ali 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 I have determined to be economicalsy practicable and that I have selected the pfacticablo method of treatment,storage,or disposai currently available to me which minimizes the present and future threat to human life and the envlronment. 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 and materials are true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that customer shall abide by The Standard Terms and C!!londltlon"n the reverse side of this Service Order. t7rt7er with en essl.t:d -ardous waste manifest(either site specific or consolidated)are subject to art TEPA Pee. These fees cover the EPA pass-through fee and administration e�lani et program. Tltass vnry based on Manifest type. Applicable fees will appear on your billing invoice. Custf mi6 Signature Date Driver Signature Date Print Name' --- Print Dr vd f arrle