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FOP'SERVICE GALL': SERVICE ORDER FORM NO.WOES004-B (8/18) <br /> DI:vN OFFICE ASBURY ENVIRONMENTAL SERVICES,-} BA SERVICE ORDER NO. ` <br /> 1-800-727-2879 <br /> FQR ACCOUNTING CALL: ""' " <br /> 562-231-1550 <br /> , WORLDOIL�� <br /> ENVIRONMENTAL SERVICES A <br /> S 300 CHEVRON WAY,DIXQN,CA 95620 A <br /> 1T '°,t I ENT <br /> �pip",i �.,, � f i� l� <br /> H ANT Oi Wil ( ��` : • ��: ! LATHROP 1-800-727-287s i-'O il'�I a T"I PRISES L! - ANrr <br /> P 701 !FARCY? , : : :.. PC BOX 8408 <br /> P WWW.WORLDOILCORP.COM <br /> n �ry TRANSPORTER EPA#CAD028277036 <br /> T LATP;ROP, r`1 14S0 <br /> S,OCK11 ON, Cr <br /> 01 <br /> -4900 <br /> CUSTOMER,* PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER.TAKEN'BY HALIDES <br /> A T CE r- a J01 1N <br /> DATE REQUIRED DATE ENTERED• NEXT SERVICE-DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 7i-2/2021" C AL00- 3815703 <br /> PART# DESCRIPTION QTY' UNIT PRICE QTY P/U `s TOTAL <br /> �c <br /> PAPER F L'TE: S PEs IDRU , <br /> i F .. Cs- BLtE s f ( 1", E i A :MP "aT NO"HARGE <br /> s <br /> .;:' .. .,. .:., a ... .. ,:.. ..:.1 '. .. - ., .... .. ..... y, - <br /> JOHK 2C 9.:4664.-900 BATCHAL <br /> , <br /> TO <br /> TAIL ti <br /> CASHA86 <br /> WASTE DIS <br /> POSAL:INFORMATIOIV <br /> NON RCRA HAZARDOUS WASTE;LIQUID(USED OILfM1ifED OILS] NATE CQDE 221' <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> t .OTHER: Iter tai redl HA.7t =2M01,ir`i i tri*" r See 111 ic"1I1Y PAPFRIP1 Acrl 1r: <br /> DESIGNATED TSDF: 5 It''A.FA ELME 11 INC.,6500 US HIGHWAY 95,YUMA,A7_8536.5 : <br /> 'ALTERN . _ F; <br /> .. .. pnµ r.� Pt "PVL. ..4 rryy 99 <br /> e:ri"QLM u 1— .. .,.. ACt: unt f1f1Anaget:Sam <br /> DRUMS P/ : EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: - <br /> (Waste Oil generator/customer MUST check ONE of the following three boxes) <br />—0-#1 j-t-have-not-mixedany-of-the-waste-describedabove-witti-any-other-hazardous_waste,-theAotaLhalide contenti-1ESSthaa_L000_ppm,_and_the_waste_does,notcontain-any PCB.s.,l-ba_v_e <br /> compiled with the requirements of the applicable California used oil management regulations to determine this is true.i agree to accept the additional charges for the disposal of this waste if <br /> the information I have provided about this waste is incorrect <br /> Q#2 1 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 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 /> ❑#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 <br /> knowledge,the only waste oil contained in my'DIY/CESOG collection tank is Soley from DlY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.l 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 and that 1 have selected the <br /> practicable method of treatment,storage,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 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 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 O r an assocs d 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 a if east program.Thes fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> xan-,- k <br /> S.Omer Signature Date Driver Signature Date <br />