Laserfiche WebLink
FOR SERVICE CALL: <br />DIXON OFFICE <br />1-800-727-2879 <br />FOR ACCOUNTING CALL: <br />552-231-1550 <br />S <br />H <br />I <br />P <br />P <br />E <br />D <br />LK <br />WORLDL <br />ENVIRONMENTAL. SERVICES - <br />7300 CHEVRON WAY, DIXON, CA 9562.0 <br />1-800-727-2879 <br />WWW.WORLDOILCORP COM <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. VVOES004-B (8/18) <br />SERVICE ORDER NO. <br />CUSTOMER # e PURCHASE ORDER # <br />DAl"E iE05 ED DATE ENTERED <br />ROUTE #f 'TRUCK # <br />NEXT SERVICE DKrE <br />CONTACT NAME <br />CUSTOMER EPA 1f <br />ORDER TAKEN BY HALIDES � <br />i <br />BILL. of LADING/ MANIFEST # <br />PAIi`I" #1 .. <br />— DESCRIPTION <br />OTY ~ <br />UNIT PRICE <br />OT`! P/U <br />TOTAL <br />TOTA L <br />CASH RECD:CHECK <br />----.TOTAL <br />.__. ._..�. .._.._...._.._.. <br />WASTE DISPOSAL INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) <br />OTHER: <br />- - <br />STATE CODE 221 <br />STATE CODE---___-_ <br />DESIGNATED TSDF: <br />ALTERNATE TSDF: <br />DRUMS i fU:_ EMPTY DRUMS:--_-_ FACILITY:-_—___-- 8SC —_-- <br />GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE SOX) <br />By signing below I hereby certify that: <br />(Waste oil generator/customer MUSTcheck ONE of the following three boxes) <br />#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 <br />compiled with the requirements ofthe applicable California used oil management regulations to determine this Is true. 1 agree to accept the additionsl charges for the disposal of this waste if <br />the information I have provided about this waste is incorrect <br />Q #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 PCHs. 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 agree to accept the additional <br />charges for the disposal of this waste if the information I have provided about this waste is incorrect <br />Q #3) This waste is from a tank which collects waste oil from household "do-it-yourself" (DIY) and/or conditionally exempt small quantity generator (CESQG) sources. To the best at my <br />knowledge, the only waste oil contained in my DIY/ CESQG 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. I agree to accept the additional charges for disposal of this waste if the information 1 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 anti that i have selected the <br />practicable method of treatment, storage, or disposal currently available to me which minhnlzes 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 materlals 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 <br />by the Standard Terms and Conditions on the reverse side of this Service Order. <br />Service Orders with 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 <br />of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br />Customer Signature <br />print Name - ------- <br />Datta Driver Signature Date <br />__ print Driver Name <br />