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FOR SERVICE CALL: <br />DIXON OFFICE <br />1-000-727.2879 <br />FOR ACCOUNTING CALL: <br />562-231-1550 <br />S <br />H <br />I <br />P <br />P <br />E <br />D <br />T <br />O <br />SERVICE ORDER <br />A S...r: r ENVIRONMENTAL <br />,,11i .1 71 DBA <br />worILD OIL <br />ENVIRONMENTAL SERVICES - <br />7300 CHEVRON WAY, DIXON, CA 95620 <br />1-800-727-2879 <br />W W W. WORLDOILCOR P.COM <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. WOES004-B (8/18) <br />SERVICE ORDER NO. <br />CUSTOMER // <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />_ ORDER-I•AKEN BY <br />HALIDES <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER -EPA # <br />BILL of LADING/ MANIFEST # <br />i <br />PART # <br />� DESCRIPTION <br />CITY <br />UNIT PRICE <br />QT'Y P/U <br />TOTAL <br />TOTAL <br />CASH RECD: CHECK <br />WASTE DISPOSAL INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) STATE CODE 22.1 <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STAT E CODE__^._. <br />OTHER: <br />DESIGNATED TSDF:-.-- <br />ALTERNATE TSDF: <br />DRUMS P/U:__ _T EMPTY DRUMS: FACILIT <br />GENERATOR WASTE CERTIFICATIO <br />By signing below I hereby certify that: <br />(Waste oil generator/customer MU <br />[] fl) I have not mixed any of the waste described above with any other hazardous wash, th+ <br />complied with the requirements of the applicable California used oil management regulations <br />the information I have provided about this waste is Incorrect <br />Iq #21 have not mixed any of the waste described above with any other hazardous waste, th, <br />have providedproper documentation to World Oil Environmental Services to rebut the presu <br />charges for the disposal of this waste if the Information 1 have provided about this waste is it <br />In any PCBs, i have <br />tposal of this waste if <br />ontain any PCBs. I <br />;opt the additional <br />0 0) This waste is from a tank which collects waste oil from household "do-it-yourself" (DI fo the best of my <br />knowledge, the only waste oil contained in my DIY/ CESOG collection tank is soley from DIY dour waste or waste oil <br />from other sources. I agree to accept the additional charges for disposal of this waste it the i <br />(All generators/ custolr <br />I certify that I have a program in place to reduce the volume and toxicity of waste generated ive selected the <br />practicable method of treatment, storage, or disposal currently available to me which minim <br />This individual signing in the space set forth below on behalf of customer represents and warrants that he/sho has the authority to bind customer, that the forgoing descriptions of waste <br />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 <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 Date Driver Signature Date <br />Print Name <br />Print Driver Name <br />