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FOR SERVICE CALL. <br />DIXON OFFICE <br />1-800-727-2879 <br />FOR ACCOUNTING CALL: <br />562-237-7550 <br />S <br />H <br />p <br />F, <br />F <br />D <br />T <br />0 <br />SERVICE ORDER <br />ASBURY ENVIRONMENTAL SERVICES, DBA <br />a, <br />WORLD OIL <br />ENVIRONMENTAL SERVICE&,, <br />7300 CHEVRON WAY, DIXON CA 95620 <br />1-800-727-2879 <br />WWW.WORLDOILCORP.COM <br />TRANSPORTER, EPA It CAD028277036 <br />FORM NO. WOES004-B (4/17) <br />SERVICE ORDER NO. <br />CUSTOMER It <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY � <br />HALIDES -- <br />w <br />DATE REQUIRED <br />ry DATE ENTERED <br />NEXT SERVICE DAM <br />CUSTOMER FPA 4 <br />BILI_ of LADING/MAN1FEST <br />PART # ��._ — I:)E.SCRIPTiOrI � <br />QTY <br />UNIT -PRICE— <br />0TY P/U.m <br />-TOTAL <br />TOTAL <br />I <br />CASH REC'D:---_.---__..-_.__ CHECK # <br />WASTE DISPOSAL. INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) <br />O HHER: <br />STATE CODE 221 <br />STATE CODE ---_ <br />DESIGNATEDTSDF. <br />ALTERNATETSDF: <br />—J---' --- <br />DRUMS P/U: EMPTY DRUMS:,--,.,— FACILITY:_-_ .------- <br />i <br />s.'➢C.1v Cnl1 t Un VVIAi) It: �_a_n I IrL-A1 IUN (NLLASt CHECK I HE AW'RUPRIALE BOX) <br />By signing below I hereby certify that: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />MV 1) 1 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 PCBs. I have complied with the requirements of <br />the applicable California used oil management regulations to cletermine 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 <br />O#21 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 <br />have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mixed w_ith other hazardous waste. I agree to accept the additional charges for the disposal of this <br />waste if the information 1 have provided about this waste Is incorrect <br />L-1#3) This waste is from a tank which collects waste oil from household "do-it-yourself" (DIY) and/or conditionally exempt small quantity generator (CESOG) sources. To the best of my knowledge, the ordy waste oil contained <br />in my DIY/ CESQG collection tank is coley from DIY and/or CESQG sources. I hive not mixed this waste oil with any other hazardous waste or waste oil From other sources. ) agree to accept the additional charges rot disposal <br />of this Waste if the Information I have provided about this waste is Incorrect <br />(All generators/ customers MUST read the following text and check the associated box,) <br />=44) If I am a large quantity generator, 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 <br />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 enviionmenq Or, if I am a small quantity generator, I <br />have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me that I can afford. <br />This Individual signing In the space ,of forth below on behalf of Customer represents and warrants that Ire/she has the authority to bind Customer, that the forgoing descriptions ofwaste and materials are true and accurate <br />as packaged, marked and labeled, are ready for transportation in accordance with applicable state and federal regulations, and that Customer shall abide and be bound by the Standard Terms and Conditions on the reverse <br />side of this Service Order. <br />Customer Signature Date Driver Signature —� <br />Print dame-- — Print Drivers Name <br />Date <br />