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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-8(8118) <br /> DIXON OFFICE. ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR <br /> N34i9749 <br /> 562 2S1 1550 TING CALL: Wv RLD OIL r r� <br /> ENVIRONMENTAL SERVICES, <br /> H W© TRACY 7300 CHEVRON WAY,DIXON,CA 95620 <br /> P 26151141 GRANT LINE RD 1 aoa727 2879 2615 W GRANT LINE RD <br /> P WWW.WORLDOJLCORP.COM <br /> D TRACY,CA 95304 TRANSPORTER EPA#CAD028277036 TRACY, CA 95304 <br /> T <br /> a (209)832,7436 (209) 83'2-7436 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> I -I 6 [-EAH PHILLIPS SGFILOULI - <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING!MANIFEST# <br /> 1111 9/202 11/1112020 CAL000440892 <br /> PART# DESCRIPTION CITY UNIT PRICE OTY PIU TOTAL <br /> VV0SCUSED OIL SER iCE CHARGE Z $95.00 $95.00 <br /> Hilo USED OIL/MIXED OILS 35C $0.00 $0.00 <br /> LEAH C--LL 92.5-339-0039 BATCH P. <br /> TOTAL <br /> CASH REC'D: 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: <br /> DESIGNATED TSDF: ASBURY ENVIRONMENTAL SERVICES-CERES,1920 MORGAN RD.,CERES,CA 95355(209)541-11 M,C4000393680 <br /> ALTERNATE TSDF: T <br /> Cross streets: Account Manager:Sale Read <br /> DRUMS PIU: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br /> By signing below;hereby certity that. <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Vol)1 have not mixed any of the waste descrfhed 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 oil management regulations to determine this is true.I agree to accept the additional charges for the disposal or this waste if <br /> the information I have provided about this waste Is Incorrect <br /> ❑ <br /> 42 l have not mixed any of the waste described above with any other hazardous waste,the total halide eontenI is GREATER than 1,000 ppm,and the waste does nal contain any PCBs.I <br /> have provided proper documerdatlon to World DIS Environmental Services to rebut the presumpilon that this waste was mixed with other hazardous waste.I agreeto accepttheaddltional <br /> charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect <br /> Irl <br /> 03)This waste Is from a tank which collects waste oil from household"do-It-yourself'(DIY)and for condi tonally exempt small quant[ty generator(CiESOG)sources.To the best of my <br /> knowledge,the only waste aft contained In my MY/CESOG collection tank Is snley from DIY andfor CESW sources.I have not mixed this waste oil 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 informal"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 degree I have determined to he 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 futurethreat to human Ilfe,and the environment. <br /> This Individual signing in the space sot forth below on behalf of customer represents and warrants Shot helshe has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurase as packaged,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that customer shati abide <br /> by the Standard Terms and Conditions an the reverse side of this Service Drder. <br /> Service Order wit an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee.These fees cover the EPA pass•lhrough fee and administration <br /> oMe ntigra .mThese fees vary based on Man[fast type. Applicable fees will appear on your billing Invoice. <br /> z� /k <br /> _U1ZV1� <br /> Customer Signature Date Dr ignatu a Date <br /> Print Name �- Print ams �— <br />