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• FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004-B (8.118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,u <br /> 5 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H 1-800-727.2879 <br /> I <br /> P WWW.WORLDOILCORP.COM <br /> F TRANSPORTER EPA #CAD028277036 <br /> r <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 LADING/MANIFEST# <br /> 2- q"q -7 2-- <br /> PART# DESCRIPTION CITY UNIT PRICE OTY P/U TOTAL <br /> TOTAL <br /> CASH RECD: CHECK # <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE. LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: _ <br /> DESIGNATED TSDF: _ <br /> ALTERNATE TSDF. <br /> DRUMS P/U: EMPTY DRUMS:_ __ FACILITY: _ BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below V hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> J 01)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,006 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 it <br /> the Information I have provided about this waste is incorrect <br /> -182 1 have not mixed any of the waste described above with any other hazardous waste.the total halide content Is GREATER than 1,060 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to World Oa 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*31 This waste is from a tank which collects waste oil from household"do-it-yourself'tDIY)andfor conditionally exempt small quantity generator(CESOG)sources.To the hest of my <br /> knowledge.the only waste oil contained In my DIY7 CESOG collection lank is soley from DIY and/or CESOG sources.I have not mixed this waste all 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 mfnrmatWn 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 tate 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 lot transportation in accordance with applicable state and federal regulations,and that customer shafl 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 td an EPA Fee. These fees coves the EPA pass-through fee and administration <br /> of the eManifesi program. These fees vary based on Manifest type. Applicable fees wilt appear on your billing Invaice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />