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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1_800-727_2878 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 582-231-1550 <br /> ENVIRONMENTAL SERVICES <br /> s 7300 CHEVRON WAY. DIXON,CA 95620 <br /> H 1-800-727-2879 <br /> 1 <br /> P <br /> P WWW.WORLDOILCORP-COM <br /> D TRANSPORTER EPA # CAD028277036 <br /> 0 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADtNGJ MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE CITY PIU TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE. LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: f - <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> DRUMS PIU: 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 tuxes) <br /> 1,Y1)I 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 /> J e2 I 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 /> J sea)This waste is from a lank which collects waste oil from household"do-it-yourself'(DIY)attdlor conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge.the only waste oil contained in my OIY1 CESQG collection lank is sotey from DIY and/or CESQG sources.I have not mixed this waste ail with any other hazardous waste or waste oil <br /> from other sources.I agree to accept the additional charges lot disposal of this waste If the InlormaUon 1 have provided about this waste Is incorrect <br /> (All generators/customers MUST react the following text <br /> I cartily 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 sel forth below an behall 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 slate and federal regulations,and that customer shall abide <br /> by the Standard Terns and Conditions on the reverse side of this Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolldated)are subject to an EPA Fee. Thess.lees cover the EPA pass-Ihrough fee and administration <br /> of the eMandest program, These fees vary based on Manifest type, Applicable fees will appear on your billing Invoice. <br /> Customer Signature f Date Driver Signature Date <br /> Print Name Print Driver Name <br />