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FORSERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8118) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-bop-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: i d33!13 <br /> 562-231-1550 WORLD QIL <br /> ENVIRONMENTAL SERVICES, <br /> s 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H P61✓AS- -?4ACY 1-800-727-2879 <br /> P W G�R,AN7 1-NE 'RD WWW.WORLDOILCORP.COM 25�15 VY GRANT L J N E RD <br /> TRANSPORTER EPA#CAD028277036 <br /> ° 7RACY, Cit 9530 TRACY, CA X5304- <br /> T <br /> o "20, <br /> CUSTOMER# PURCHASE ORDER# ROUTI_# TRUCK# CONTACT NAME ORDER'TAKEN BY HALIDES <br /> VID1551­.5 CER-SSA IISA;v? RFAID smar!ine <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 71012020 CAL0004 ^89? oxF >i <br /> PART# DESCRIPTION QTY UNIT PRICE OTY PIU TOTAL <br /> PC= PAPER=!LTE>RS PES? DRUM � $85.00 C8�.aC <br /> OFnR Oil"F?LTER.DR;.iM REPL AGEMENT- NO CP'ARGE .;0.00 I X0.00 <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> HON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS) STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) . STATE CODE <br /> C OTHER: �dnu. rar.u �hr�rtr�i IC tnrR�r� s ns In rr�li u nr nf�r� al ac Ifi SII r�sa� nc c}- c �M r,,.s ?5 a <br /> DESIGNATED TSDF: YES MANAGEMENT.INC.,6500 US HIGHtMAY 25,YUNTA,AZ 8530-5 <br /> ALTERNAT F: <br /> Aawurlt Manager.Sam Read <br /> DRUMS PW_4;)_ EMPTY DRUMS: FACILITY: B.SC <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 /> Q#1)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 /> compiled with the requirements of the applicable California used all management regulatlons to determine this Is true.I agree to accept the additional charges for the dlsposal of this waste it <br /> the Information I have provided about this waste Is Incorrect <br /> ❑#2 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 411 Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree fn accept lha Rdditional <br /> charges for the disposal of this waste If the information I have provided about this waste Is Incorrect <br /> ❑03)This waste Is from a tank which collects waste oil from household"do-it-yourself"(DIY)andlor'conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained In my a]Y1 CESOG collection tank Is Soley from ON and/or CESOG sources.I have not mixed this waste all with any other hazardous waste or waste all <br /> from other sources.I agree to accept the additional charges ford1sposal of this waste if the informatlon 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 dog ree I have determined to ba economically practicable and that I have selected the <br /> practicable method of treatment,storage,ordlsposal currently available to me which minimizes the present and future threat to human Ilfe and the environment. <br /> ThIs Indlv]dual signing In'the space set forth below on behaItof customer represents and warrants Shat helshe has the aulhorlty to bled customer,that the torgoing 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 0rders with an associated hazardous waste manifest(either site speclllo or consolidated)are subject to an EPA Fee. The s cover the EPA pass-through fee and admInlstration <br /> of the eManlfest program. These fees vary based on Manifest type. Appllcable tees will appear on your bli ling InveIce. <br /> /Customer Signature Date Driv Signature Date <br /> Print Name Print Driver Name <br />