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FOR19E19,VICE CALL" SERVICE ORDER FORM NO.WOES004-B (8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: N3330752 <br /> 562-231-1550 GWORLDOIL <br /> ENVIRONMENTAL SERVICES,. <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H <br /> P I ANTONINI TRUCKING- ANT005- 1-800-727-2879 <br /> E P 19800 GALE AVE WWW.WORLDOILCORP.COM P.O. BOX 8468 <br /> D TRANSPORTER EPA#CAD028277036 <br /> T Huron,CA 93234 STOCKTON, CA 95208 <br /> 0 <br /> (209) 249-7503 <br /> (a 2, <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ANT005 MUST OBTAIN PO RGUTE 118 JOSE MEDINA SCHEDULED-1 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE.DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 8/24/2020 8/18/2020 CAL000234968 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> WOSC USED OIL SERVICE CHARGE 1 $160.00 $160.00 <br /> WO USED OIL/MIXED OILS $0.00 Zoo $0.00 <br /> BATCH# Lr/L1 <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED 01),S) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCO'C'SOLUTIONS). STATE CODE <br /> OTHER: 4 <br /> L DESIGNATED TSDF:WORL )OIL-SAN JOAQUN_=, 14287E MANNING AVE PARLIER,CA 93648,(559)498-0240,CAL000102751 <br /> ALTERNATE TSDF: <br /> Cross Stroets, Account Manager:Jim Dillon <br /> DRUMS P/U: 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 /> 4 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 /> 'plied 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 /> 11#2 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATERthan 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 /> LJ#3)This waste is from a tank which collects waste oil from household"do-it-yourself"(131Y)and/or conditionally exempt small quantity generator(CESOG)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 CESCIG 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 I 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 I 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 Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover thEPA pass-through fee and administration <br /> of the eManifest program. These fees very based on Manifest type. Applicable fees will appear on your billing invoice. <br /> CustoNer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />