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" FOR SERVICE CALL : SERVICE ORDER FORM NO . WOES004= B (8/18) <br /> DIXON OFFICE ASRURY ENVIRONMENTAL SERVICES , DBA SERVICE ORDER NO . <br /> 1 -800-727-2879 <br /> I I2 % CC 358 <br /> FOR ACCOUNTING CALL : ; <br /> 562-231 - 1550WORLD OIL <br /> ' .. <br /> 4f <br /> ENVIRONMENTAL SERVICESr, <br /> �A' <br /> S 7300 CHEVRON WAY, DIXON , CA 95620 <br /> H � BRIAL. 1 E"i �� Y�°'�. LEy4 � r= STERN 100T`ORS - C. , <br /> 1 -800-727-2879 ,� ;� v + _ r <br /> P 145 'W YOSP HI �i .; Imo. ` V YC) , 1111 .Iti Aivr4 <br /> P WWW.WORLDOILCORP. COM <br /> E TRANSPORTER EPA # CAD028271136 f <br /> T MAi'�TECA , CA 9 ? . a IJ �Ntt kA Cry P,5 : ! <br /> 0 0 1 Sfgt )V ) tu,».. 'i i 48 <br /> �1 , <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUC &C # CONTACTS, AME ORDER TAKEN BY HALIDES <br /> DIX_ a . v LEONAR <br /> FItS <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # <br /> PART # DESCF IPTION CITY UNIT PRICE QTY P/U TOTAL <br /> �;` ,k� 101UIJ VACI.Ii011 T 4A 13Fit�' RTA T ION rr $ 105, 00 ;20;d S o <br /> T RKW TRUCK, WA SHOLTI' 00 $ , . 01+ <br /> I�J1 Ei+r' kril i= EPA; I t: Af i (' tlis'�4 SITE St EC C 4th �i ,�� hllt ��i 1 $ 10 , CIO ,x; 10 . 00 <br /> PL;; PICK 'Ii}.; 1Pd.Asa16E OL U � EVLRY' Me)NDAY BATCH <br /> TOTAL <br /> CASH REC ' D : CHECK #. <br /> WASTE DISPOSAL INFORMATION <br /> NON- RCRA HAZARDOUS WASTE , LIQUID (USED OIUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOL S WASTE , LIQUID ( ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER : dS ?" LNC'+ 7" � `� ,'t <br /> DESIGNATED TSDF : � ee�c, C' <br /> ALTERNATE TSDF : <br /> Cross Streets 4 �3'' :� � df`C Acc"Iu 'r• 1fiUnae ;xrl v afr Read <br /> DRUMS P/U : EMPTY DRUMS : FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION ( PLEASS�CHECK THE APPR &,,RIATE SOX) <br /> a _ <br /> By signing below I hereby certify that: <br /> (Wa to oil generator/customer MUST check ONE the following � <br /> of ree boxes) <br /> Q #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 of thea plicable California used oil management regulations to determine this Is true. 'AN <br /> to accept the additio TI charges for the disposal of this waste If <br /> the information I have provided about th s waste is Incorrect r a <br /> n #21 have not mixed any of the waste described above with any other hazardous waste, the total halide content is GREATER than 1 ,000 pp)0and he waste does not contain any PCBs. I <br /> have provided proper documentation to orad Oil Environmental Services to rebut the presumption that this waste wasolpt! with other hazardous -waste. I agree to accept theadditional <br /> charges for the disposal of this waste if the Information I have provided about this waste is Incorrect <br /> 0 #3) This waste is from a tank which collects waste all from household "do•it-yourself' (DIY) and/or conditionally exempt small quantity gerleratgr ( ESQG) sources. To the best of 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 wgsfe ol�h✓Ith any other hazardous waste or waste oil <br /> from other sources, i agree to accept th additional charges for disposal of this waste If the Information I have provided about this waste is Incorrect <br /> (All generators/ customers MUST read the following to <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 and that l have selected the <br /> practicable method of treatment, storag , or disposal currently available to me which minimizes the present and future threat to human life and the^environment, <br /> This Individual signing In the space set Orth below on behalf of customer represents and warrants that he/she has the authority to bind customer, that the forgoing descriptions of waste <br /> andmate[[I�Islam true and accurate as p ckaged, marked, and labeled, are ready for transportation In accordance with applicable state and federal regulations, and that customer shall abide <br /> by theaStft.dard arms and Conditions a the reverse side of this Service Order. <br /> Set I 'e rr l�rs wit, 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 /> ofit eje nitest pJo ram. These fees vc ry based on Manifest type. Applicable fees will appear on your billing invoice, <br /> t <br /> qsbrrfir_SigAture Date Driver Signature Date <br /> r . j t ` <br /> PrintfName Print Driver Name <br />