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FOIA SERVICE CALL : SERA/ IGE ORDER FORM NO . WOES004 _ 13 ( 8/ 18 ) DIXON OFFICE. ASBURY ENVIRONMENTAL TAL S IRVI ES , DBA SERVICE ORDEPI N0a 14'100727-2879 - - - - FOR ACCOUNTING CALL : ., 562 231 - 1550 V 101 ENVIRONMENTAL SERVICES S 7300 CHEVRON WAY, DIXON , CA 95620 d I 1 -800 - 727 -2879 P WWW, WORLDOILCORP. COIAA E D TRANSPORTS n EPA P C; AD028277036 7 O CUSTOMER t PURCHASE ORDER # ROUTE # TRUCK iff CONTACT NAME. ORDER TAKEN BY HALIDES DATE �-c� s� lr-2FDDATE ENTERED NEXT SERVICE DATE CUSTOMER crA # BILL of LADIlvi MANIFEST # 1 114ART k f _m DESCRIPTION .� OTYUNIT PRICE OTY Pivt TOTAL TOTAL C A S H FC ' D : CHECK # WASTE DISPOSAL INFORMVNTION NOWRCRA HAZARDOUS WASTE , LIQUID ( USED 01UMIXED OILS) S'rXRE CODE 221 NON - RCRA HAZARDOUS WASTE , LIQUID ( ETHYLENE GLYCOL SOLUTIONS ) STATE: CODE---- OTHER : ODE_OT € 1ER : DE SIGNxrED TSDF :ALTERNATE TSDF : ----- - --- --- - -- I313tUMS P/U : EMPTY DRUMS : - - FACILITY: RSC GENERATOR WASTE CERT IFICATION ( PLEASE CHECK THE APPROPRIATE BOX) by signing below I hereby certify that : ( Waste oil g ner for/cult rner MIUS T check ONE of the. following three boxes) [� !ti ) 1 have riot mixed any of the waste described alcove with any other hazardous waste, the total halide content Is LESS than 1 ,000 pprn , and the waste does not contain any PCBs. I have compiled with the requirements of the applicable California used oil management re>guiations to determine this Is true. I agree to accept the additional charges retire disposal of this waste if the Information I have provided about this waste Is incorrect Lq ,"2 1 have not mixed arty of the waste described above with any other hazardous waste, the total halide content is GREATER than 1 , 000 ppm, and the waste dens 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 vraste. I agree to accept ttre additional charges for the disposal of this waste If the Information I have provided about this waste is Incorrect Q 43) phis waste is from a tank which collects waste oil from household "do-ii-yourself" (DIY) and/or conditionally exempt small quantity generator (CESOG) sources . To the best of my knowledge, the only waste oil contained in my DIY/ CESOG collection tank is coley from DIY and/or CESOG sources. I have not mixed this waste oil 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 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 selected the Practicable method of treatment , storage, or disposal currently available to tie which minimizes the present and future threat to human life and the environment. This individual signing fn the space set forth belovi on behalf of customer represents and warants that fielshe has the authority to bind customer, that the forgoing descriptions of waste and materials are true and accurate as packaged , marked, and labeled , are ready for transportation In accordance vrith appiicrible state and federal regulations, and that customer shall abide by the Stannard Terins and Conditions on the reverse side of this Service Order. Service Orders 6vith 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 adminislrahon of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. Customer Signature Date striver Signature rate Print: Narne Print Driver Nape