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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18)
<br /> bIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DSA SERVICE ORDER No.
<br /> 1-800-727-2879
<br /> FOR ACCOUNTING CALL: WORLDOy. IL N135-21367
<br /> 562-231-1550 Wi
<br /> ENVIRONMENTAL SERVICES. 2-A
<br /> S7300 CHEVRON WAY,DIXON,CA 95620
<br /> t 11A?[r'1 a ri'�:,Rll,`.Y 1-800-727-2879
<br /> P t5%ff L^�RA1,JT 1_IN,E i t: WWW.WORLDOILCORP.COM 2615 X11{GRI NT UNE RD
<br /> D TRANSPORTER EPA#CAD028277036
<br /> T TrR.A04,C.,A 9!3.3,34 TRACY,Y, C A,05304
<br /> 0
<br /> ('20$) 632-7433 (209) 632-7430-
<br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES
<br /> I1(1I'..{655 i (�U!L... 111 C LEAH lP (I.. S
<br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST#
<br /> 3/3/202" ;'Al 000440892
<br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL
<br /> WOSIC. USED COIL,S, tViC'E C?-1iR 3; 1 �95.Ci3 $Z.00
<br /> k1r%f0 LiSED OIL/+ViiXEl-s Olt__= 400 $0.00 $0.00
<br /> !_ AHC -i..925 -r7d39 LRTrF1~ ___.. 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: •,.— .;:• w
<br /> ALTERNATE TSDF• .. . _ ,.. „ t_ ., .,:�,ti ',•..�..,,,-��._ a..", �.,�� ,, ...., , ,. 2 ,' 1-1825,
<br /> G r.t-.:t:^7%i e e..t, �k686k1'1�i4�lo�i"aaPr' �&iR Iti1388
<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 /> All)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 /> complied 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 if
<br /> the information I have provided about this 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 ppm,and the waste does not contain any PCBs.1
<br /> have provided proper documentation to World Oil 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 /> ❑#3)This waste is from a tank which collects waste all from household"do-it-yourself"(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my
<br /> knowledge,the only waste oil contained in my DIV/CESOG collection tank Is soley from DIY and/or CESQG 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 information 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 be economically practicable and that t 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 s a 5th 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 an rate as pac ed,marked,and labeled,are ready for transportation in accordance with applicable state and federal regulations,and that customer shall abide
<br /> by the Standard Te and Conditions on the averse side of this Service Order.
<br /> Service Or s tth an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee.These ees cover the EPA pass-through fee and administration
<br /> of the a nlfe pregra The fees vary based on Manifest type. Applicable fees will appear on your billing invoice.
<br /> /= _._. �ate
<br /> CU�sW -31g atu e D e /� Driver Signat re
<br /> Print Name Print riv m
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