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i <br /> FOR SERVICE CALL: SERVICE ORDER FORM NO.-WOES004-B{8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: N3252561• <br /> 562-231-1556 WQRLD'0IL <br /> ENVIRONMENTAL SERVICESim <br /> s 7300-CHEVRON WAY,bixQN,CA9562Q <br /> " MIDAS-GRANT LINE RD 1-800-727-2879 <br /> P 2615 W GRA1 T LINE•R!] WWW.WORLDOILGORP.GOM 26.15 VV G-RANT LINE RD <br /> P TRANSPORTER EPA#CAD028277036 <br /> T T RACY,CA 96304 TRACY, CA 95304 <br /> 0 - (209) 832-7436 (2Q9} 332-74313. <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> N1i06F5 OLJTE 11( 4,W 'LEAH PHILLIPS SCHEDULED-1 <br /> DATE REQUIRED 'DATE ENTERED NEXT'SERVICE DATE CUSTOMER EPA# BILI,Of LADING/MANIFEST# <br /> 5129/2020 5/21712020 GAL000440892 -' i 2 <br /> PART# DESCRIPTION QTY` UNIT PRICE OTY PIU TOTAL <br /> WOSC USED OIL SERVICE CHARGE 1 ' $95.00 $95.00 <br /> WO USED 01L I ViiXED OILS 400 $0.00 $0.00 <br /> LEAH C LL 925-339.01739 BATCH# <br /> TOTAL <br /> CASH REO'D: . CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NOT-.RCRA HAZARDOUS WASTE,LIQUID(USED OIIJMUCED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE-GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: - <br /> DESIGNATED TSDF: fillERVIrGERE MORgt-A�!RD CE ES M 95a58 2129A41. 926 ��4L9€SCi393$� <br /> ALTERNATE TSDF: <br /> •Crbss Strep.ts Account Mariager:Sam Read <br /> DRUMS PN: EMPTY DRUMS: FACILITY: SSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> Byslgning below I hereby certify that: <br /> (Waste oil generator/customer MUST Check ONE of the following three Foxes) <br /> g�#1)l have not mixed any of the waste described ahpvc with any other hazardous waste,the total halide content is LESS than 1,(100 ppm,and the waste does not contain any PCBs,i have <br /> compiled with the requirements of the applicable Callfornio used oil management regulations to detorminothis-is true.I agree to accept the additional charges for the disposal of this waste If <br /> the information I have provided shout thin,waste Is Incorrect <br /> ❑#21 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is GREATER than 1,000]rpm,and the waste does not contain any PCEs.I <br /> have provided proper documentation to World 411 Environmental Services to rebut the presumption that this waste was_mixed with other hazardous waste,I agree to accept She additional <br /> charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect' ' <br /> ❑43)This waste is from a tank whlcIt collects waste all from household"do•it-pourself"(DIY)and/or conditionally exempt smalf quantity generator(CESGG)sources.To the best of.my <br /> knowledge.the only waste all contained in my DIY/cEsciG collection tank Is coley from DJY and/or CESQQ sources.I have not mixed this waste oil with any other hazardous waste or waste all <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 a <br /> I certify that 1 have a program In place to reduce the volume and toxlclty 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 WE!and the environment.' <br /> This individual slgning In the Space set forth belowon behalf of customer represents and warrants that helshe has the authority to bind'oustomor,that the forgoing descriptions at wasia <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 ver the EPA pass-through tee and scintinistration <br /> of the efdanifest program. These fees vary based on Manifest type.,ApplJcailee wi11 appear on your bllling Invoice. <br /> Customer Signature ate /]river ure fate <br /> Print'Name Print Name <br />