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t <br /> 3 <br /> ,R StRVICE CALL: SERVICE ORDER <br /> FORM No. WOEs004e (8/18) <br /> XON OFFICE ASEURY ENVIRONMENTAL SERVICES, SERVICE ORDER NO. <br /> 300-727-2879 <br /> i <br /> )R ACCOUNTING CALL: <br /> a2-231-1550 WORLD OIL <br /> ENVIRONMENTAL SERVICESn., <br /> 7300 CHEVRON WAY,DIXON,CA 95620 <br /> 1-800-727 2879 <br /> P :A­11WWW.WORLDOILCORPaCOM <br /> E TRANSPORTER ERA#CAD023277036 <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER # ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> Vt <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# SILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> ;l <br /> p,,o ikt 2-L( <br /> ACCOUNT# e.0,90cl <br /> R/O# <br /> APPROVED <br /> TOTAL <br /> CASH RECD: CHECK# <br /> /ASTE 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 TSM=: <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: SSC_-- i <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE PPROPRIATE SOX) <br /> By signing below I hereby certify that: <br /> (Waste oilgenerator/customer MUST check ONE of the fo owing three boxes) <br /> I.I#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 1 pm,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 acce. the additional charges for the disposal of this waste if <br /> the information I have provided about this waste is incorrect <br /> "I#21 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 1, 0 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 of r 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 oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quart ty generator(CESQG)sources,To the best of my <br /> knowledge,the only waste oil contained in my DIY!CESQG collection tank is soley from DIY and/or CESQG sources.I have not mixed v1p 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 wa q is incorrect <br /> (All generators/customers MUST read the folio,ving 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 ecor i'nically practicable and that I have selected the <br /> practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to humap life and the environment. <br /> This individual signing in the space set forth below on behalf of customer represents and warrants that he/she has the authority to bin Customer,that the forgoing descriptions of waste <br /> and materials,are true and accurate as packaged,marked,and labeled,are ready for transportation in accordance with applicable stat nd federal regulations,and that customer shall abide <br /> by the Standard Terms and Conditions on the reverse side of this Service Order, <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fei s.cover the EPA pass-through fee and administration <br /> ,IA.eManifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Sid ure Date Driver Sign ature Date <br /> krf ., <br /> Print Name _ Print Drivel Name <br />