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FOR SERVJQ'f_CALL,: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-500-727-2879 - <br /> FOR ACCOUNTING CALL: I <br /> N3373261 <br /> 562-231-1550 GWORLPOIL <br /> ENVIRONMENTAL SERVICES,. <br /> S 300 CHEVRON 1-800-727-2879 WAY, DIXON,CA 95620 <br /> H ANTONIN! ENTERPRISES LLC- LATHROh� ANTONINI ENTERPRISES LLC - ANTO <br /> P 7071 ( 'ARC`f PKWY <br /> P WWW.WORLDOILCORP.COM PO BOX 8466 <br /> � TRANSPORTER EPA#CAD028277036 <br /> T LATHROP,CA 95330 STOCKTON, CA 95215 <br /> (209) 993-8695 (209) 466-4900 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> A 608 C -86 /_/ JORN TCHECIULECI-I <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DA`TEE CUSTOMER EPA# FILL of LADING/MANIFEST# <br /> 10/2120201 9/23f2020 cAL000385703 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> OFDR OIL FILTER DRUM REPLACEMENT- NO CHARGE 2 <br /> PF PAPER FILTERS PER DRUM 2 <br /> JOHN 2 -466-4900 BATCH <br /> TOTAL <br /> CASH RECD; CHECK <br /> WASTE DISPOSAL INFORMATION <br /> NOIR-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) SPATE CODE j <br /> OTHER: N�7N RCRA HAZARDOUS,Vit__#�S SCS ICl(�xILY f�dIP�ERtP 4�1 I F1 T RS!DEI3#�I4) ,tom Codei <br /> DESIGNATED TSDF: YES MANAGEMENT, INC.,6500 US HIGhIWAY 95,YUMA,AZ 55365 —- <br /> ALTERNATE TSDF: <br /> Cross: Account Manager:Sam Read <br /> DRUMS P/U:r/i EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below I hereby certify that: <br /> (Taste oil generator/customer MUST check ONE of the following tree boxes) <br /> Q #i)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 /> complied with the requirements of the applicable California used oil management regulations to determine this is true.1 agree to accept the additional charges for the disposal of this waste if <br /> the information I have provided about this waste is incorrect I <br /> Q #2 1 have not mixed any of the waste describedabovewith 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 /> i <br /> Q #3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)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 waste oil with any other hazardous waste or waste oil <br /> from other sources.1 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 react the following text j <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 indiv' ual 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 mate Is 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 St dard Terms and Conditions on the reverse side of this Service Order: <br /> Serviders4h an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. Thes fees cover the EPA pass-through fee and administration <br /> o e e nifest p gram. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> site <br /> 1, <br /> us' r Si mature �( Date river Signature Date <br /> yr r <br /> r- �C- <br /> Print Name Print Driver Name <br />