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FOR SERVICE CI 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: N3292Q9O <br /> 562-231-1550 WORLD OIL <br /> ENVIRONMENTAL SERVICESTM <br /> S 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H <br /> ' ANTONINI TRUCKING- ANT005- 1-800-727-2879 <br /> P <br /> EP 19800 GALE AVE WWW.WORLDOILCORP.COM P.O. BOX$468 <br /> D TRANSPORTER EPA#CAD028277036 <br /> ' Huron, CA 93234 <br /> 0 STOCKTON, CA 95208 <br /> (209) 249-7503 �q Z <br /> 91 (209) 249-7503 <br /> CUSTOMER# I PURCHASE ORDr:R# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ANT005 MUST OBTAIN PO PAR-97 900 JOSE MEDINA ipacherco <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE . CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 717120726 CAL000234968 <br /> PART# DESCRIPTION QTY UNIT PRICE CITY PIU TOTAL <br /> OF USED METAL OIL AND GASOLINE FILTERS $55.00 s&&GG, <br /> OFDR OIL FILTER DRUM REPLACEMENT- NO CHARGE $0.00 $0,00 <br /> 13ATCH I TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> FNON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER:_11E OUSVqAST"OL"I'LTERS-CONTAINING-OttST*TE-COBE 223 <br /> NA <br /> ALTERNATE <br /> 45119� <br /> ALTERNATE TSDF: YES-MANAGE-M-E�I-T-ANO—,650"S-HIGHWAY-95,-YUMATA7--8536�-- <br /> GrosSrst <br /> �U.-7 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 /> #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 /> 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 /> Fl#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 t 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 43)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 MY/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 /> (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 the EPA pass-through fee and administration <br /> of the eManifest� ram./�The fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> /7y D <br /> Customer Signature Data friverSignig' n re <br /> Date <br /> Print Name Print Drier Nam, <br />