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FOR SERVICE CALL? k,kf= "" SERVICE ORDER FORM NO.WOES004 B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 <br /> FOR ACCOUNTING CALL: (b'ii?+;0,i 7,, <br /> 562-231-1550 >'WORLD OIL .--� <br /> ENVIRONMENTAL SERVICEST. �� f <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 t <br /> H r 'I fsR "~ir-:':i 1..:, I.. I tt }=' 1-800-727-2879 A a!i,'i 411 1S 1:f4!L <br /> P <br /> WWW.WORLDOILCORP.COM , <br /> D TRANSPORTER EPA#CAD028277036 1♦ <br /> ;ij $rf;{• T:9 i 1-"09),4 6 ..A�X!0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 1,+'iC'i+ '•;` t'}j,.it :,f tl![.i.i.:} i <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> .+� a Ia„ i'.,1l,•' r �..+.��+.,! ...fa I.+,�1�jt'1�.$Ij '«+:. <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> I.. i . ',.`!I -''At i► .,H5 ,kaki" 1 li1r:; t+ I f* <br /> 1.) !d !.I '.it l F F I../; :I 'uP tIT. td J ..#-4!�I^�,._s(-: � '7 <br /> r. <br /> _.... ........... TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: t,ii . A}� aid i F Y '!`1_,",��c :%I ii•i! 1, rf1, , i i"g)1;'� ii1!1."� f�1 !I':i its++. s,•r_ t ,:" 3`sU+) a t)2t.lt> l}t;t <br /> ALTERNATE TSDF: <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 /> 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 /> complied 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 /> 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(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 CESQG 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 /> x <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 So 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 the EPA pass-through fee and administration <br /> of the eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> . <br /> 14 <br /> Cu'stome' r Signature` `4 Date Driver Signature Date <br /> Print'Namd Print Driver Name ` <br />