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FOR SERVICE CALL: SERVICE ORDER FORM NO_WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: W�RLD OIL- <br /> ENVIRONMENTAL <br /> 1 L N:3277659 <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES. s <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H <br /> MIDAS-GRAN'r LINE RD 1-800-727-2879 <br /> P 2615'W GRANT LINE RD WWW.WORLDOILCORP.COM 2615 VV GRANT LINE RD <br /> n TRANSPORTER EPA#CAD028277030 <br /> T T RACY,CA 95304 TRACY, CIS 95604 <br /> 0 (209) ,532-74313 (209)832-7436 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ID855 I.0 T C 1'I ff t,160 LEAH Pl-14LLIPS SCHEWU=-D-1 <br /> DATE REQUIRED DATE ENTERED Nr=XT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 61201202.01 6/1712020 CAL000440892 E� . <br /> PART# DESCRIPTION OTY UNIT PRICE O L IU TOTAL <br /> \IVOSC L:S>wU 4iL SERVICE C-HARGE 1 $95.00 � $95.00 <br /> WO '_'SE CIL 1 r !XF-D OILS $0.010 $0.00 <br /> 1E_' C: ��5-330-��3= ^i f 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 /> DESIGNATED TSDF: .y rn�..- r-rr +•. .... .. <br /> .ivw....�. ....... .v......-i ri �....- ✓-.a. ti -.�.T�: �i-,1rI.,67 I�Vl Y�{VYVYw�Z.wv�v Evia y �v.r.rti.y J-51i <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 boxes) <br /> ❑41)1 have not mixed any Of the waste described above with any other hazardous waste,the total halkle canwnt Is LE55 than 1,000 ppm,and the waste does not contain any PCBs.I have <br /> compiled with the requIreme his of the appilcaWe Callfomto used all management regulations to determine this IS true.t agree to accept the additlonaI charges for the disposal of this waste 11 <br /> the Informatlon I have provided about this wasle is incorrect <br /> ❑421 have not m}xed any of the waste described above with any other hazardous waste,the total haitde content is GREATER than 1,000 ppm,and the waste does not contain any PCBs.i <br /> have provided proper docu me ritation to World CII Environmental Servlces to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional <br /> charges for the dlspasal of this waste If the Information I have provided about this waste is incorrect <br /> ❑t3)This waste is from a tank which actleels waste oil from household'do-It-yourself"{DIY}and/or conciltion ally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste of)contained In my DIY!CFSOG collection tank is soley from DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste 011 <br /> from other sources.I agree io accept tho addltinnal charges far disposal of this waste If the Inlormativn I have provided about this waste Is Incorrect <br /> (All generators/customers MUST read the following text <br /> I coMity that I have a program In place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically practicable and that I have selected the <br /> practicable method of aiment,storage,or disposal currently available to:and Which minimizes the present and future threat to human Iffe and the environment. . <br /> r, <br /> This individuals hing n the space set forth below on behalf of customer represents and warrants that hefshe has the authorlry to bind customer,that the forgoing descriptions of waste <br /> and materials a true nd accurate as packaged,marked,and la red,are ready for I ra nspartat lo n In accordance with applicable state and federal regulatlons,and that customer shall abide <br /> by the Stand d Ter an o ditons on The reverse side of his Service'Order. <br /> Service O ors wl a Safi ated hazar a waste ma est{either site specific or consolidated)are subject to an EPA Fee. These fees ver the EPA pass-through fee and administratlon <br /> of th a nlfest ro am. ese fee a based on nifest type. Applicable fees will appear on your billing Invoice. <br /> L? <br /> Cu er S- n re `Date D Si Date <br /> qndi \4 <br /> Print 161de Print D ' arne <br />