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{ SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA SERVICE ORDER NO. <br /> 1-800-727-2879 N'31035.317 <br /> FOR ACCOUNTING CALL: worIL D OIL 562-231-1550 � <br /> ENVIRONMENTAL SERVICES, <br /> H O AND i<i, OSA T PJ�C:Y GFaE�✓I';. ;..ET-O/�T4� UQ CHEVRON WAY,DIXON,CA 95620 <br /> I 1-800-727-2879 <br /> P 3400 "WTO PLAZA\PIAY 11400 AUTO PLAZA WAY <br /> P WWW.WORLDOILCORP.COM <br /> ° TRACY, CA 0530 TRANSPORTER EPA#CAD028277036 T!1ACY, C A °S3'0 <br /> o (209) 835-4500 (20LI) 3,35-4500 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK`# CONTACT NAME ORDER TAKEN BY HALIDES <br /> .IUriiVlJt_ITN IFER srrlamnuz <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 11 1= ,119 L;ALUU033U42,5 <br /> pal�O <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> Ab::UFt r3,n6K F_-IN 1 4 <br /> 55-C/T1ti 55 GALLON C/1-METAL DRUM ? $52.00 <br /> MIXED MIXED FUELS r_1E_R DRUM i :12 '5.00 $22.5-5.00 <br /> rIS EMAN!FEST EPA FEE&ADftRiN • S;TE PEC FIC MAN IFES- $25.00 � $25.00 <br /> 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: <br /> ALTERNATE TSDF: u <br /> CrossJ_i VCO 111C tlCCt7 i!ii.4lfiBgEr; _r.1t ptLar: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> R E: <br /> k <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIAT BOX) <br /> By signing below I hereby certify that: <br /> j ; <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> (] #1)1 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 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 /> Q #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.I <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 /> Q #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 DIY/CESOG collection tank Is soley from DIY and/or CESOG sources.l have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.l 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 1 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 space set forth below on behalf of customer represents and warrants that hefshe has the authority to bind customer,that the forgoing descriptions of waste <br /> and materlals are true and accurate as packagers,marked,and labeled,nre ready for wrisporlatlon In accordance with applicable stata and federal regulations,and that customer shall abide <br /> by the Standard Terms and CondiIlons on the reverse side of this Service Order. <br /> i <br /> Service Orders with an associaleA hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and adminislration <br /> of thea fest pro :Zes vary based on Manifest type. Applicable fees will appear on your billing Invoice. <br /> Customer Signature Date Driver Si g1 afore Mate <br /> - <br /> rl..a Nt.�.r... morin#r]rivrcr AFnrnn <br />