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FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004 - 13 ( 8118 ) DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES , DBA SERVICE ORDER NO , 1 -$00-727.2879 FOR ACCOUNTING CALL : WORLD OIL, 562-231 - 1550 , ENVIRONMENTAL SERVICES .,r RFr S 7300 CHEVRON WAY, DIXON, CA 95620 P1 .800.727- 2876 PAE? 2 7 201 P WWW.WORLDOILCORRCOM E TRANSPORTER EPA # CAD028277036 V T ,�� I � ONMtNTAL 1-lEALTH O DEPARTMENT CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL 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 P/U : 1 EMPTY DRUMS ; FACILITY: BSC GENERATOR WASTE CERTIFICATION ( PLEASE CHECK THE APPROPRIATE BOX) By slgning below I hereby certify that: ( Waste oil generator/customer MUST check ONE of the following three boxes) 0 #1 ) 1 have not mixed any of the wasia described above with any other hazardous waste, the total hallde con lont Is I. ESS than 1 , 000 ppm, and the waste dons 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 forthe disposal of this waste if the Information t have provided about this waste is Incorrect o #2 I have not mixed any of the waste described above with any other hazardous waste, the total hallde 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 additional 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 collects waste oil from household "do-Il-yourself' (DIY) and/or conditionally exempt small quantity generator (CESOG) sources. To the best of my knowledge, the only waste oil contained in my DIYf CESOG collection tank Is soley from DIY andforCESOG 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 (All generators/ customers MUST read the following text 1 certify that 1 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 practicable method of treatment, storage, or disposal currently available to me which minimizes the present and tenure threat to human life and the environment. This individual signing In the space set forth below on behalf of customer represents and warrants that helshe has the authority to bend 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 Condltlons on the reverse side of this Service Order. Service Orders wlth an associated hazardous waste manifest (either site specific or consolidated) are subject to an EPA Fee, These fees cover the EPA pass-through fee and administration of the emanilest program. These felts vary based an Manifest type. Applicable fees will appear on your billing invoice. 1 r Customer Signature Date Driver Signature Date I Y . r Ora Print Name Print Driver Name Z ' d 260Z6V66OZ tsel d69 : Zle ' 66LZ -1eN