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FOR SEkVICE CALL: 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: N3292091 <br /> 562-231-1550 GWORLDOIL <br /> ENVIRONMENTAL SERVICES, <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H <br /> P ANTONINI TRUCKING-ANT005- 1-800-727-2879 <br /> E 19500 GALE AVE WWW.WORLDOILCORP.COM P.O. BOX 5455 <br /> D TRANSPORTER EPA#CAD028277036 <br /> o Huron, CA 93234 STOCKTON, CA 95205 <br /> (209) 249-7503 (209)249-7503 <br /> 3z g <br /> CUSTOMER# '15—URCHASE-014DER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ANT005 MUST OBTAIN ISO AR-97 e, JOSE MEDINA. ioacheco <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 7/712020 CAL000234968 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> RF PAPER ALTERS FUER DRUM $125.00 <br /> OFDR OIL FILTER DRUM REPLACEMENT-NO'CHARGE $0.00 $0.00 <br /> BATCH <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 /> DESICNAT SES Ndld!IAt�EtUIENT,STE`SOLID(e4LY-PAP­ERfi1L48TIC;FILTERS/DEBRIS) State Cade 352 <br /> INC,5560 tJ IS HIGHWAY 0,1t1NrA,A7€5365 <br /> ALTERNATE TSDF: <br /> Aa aunt(vtana er:JIM Dillon <br /> DRUMS P/U:_�K 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 /> U#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 /> U 42 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 quantitygenerator(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 /> (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 =manifestste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> on Manifest type. Applicable fees will appear on your billing invoice. 7 <br /> 43— C l�V l <br /> Customer Signature Dade Driver Signature Dane <br /> 171C (�2 <br /> Print Name Pri t nrivar Nama <br />