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"'r�PR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-80Q-727-2879 SERVICE ORDER NO. <br /> N3-'-S'517 <br /> FOB ACCOUNTING CALL: �]WORLD OIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES, <br /> HQ I�N�7 ?il, 7i"SA T f�G'Y GF IE'�c=O;..ET- C?!+,(„7C�,,T,CHEVRON WAY,DIXON,CA 95620 <br /> I 9-800-727-2879 <br /> :�4n' `,LTO P. �A V As 14CC ALl7P LAZm /Or <br /> P WWW.WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CAD028277036 <br /> ° .. AC:Y, CA 953,3' TRA,`I`, "',A P53-04 <br /> T {209, °l5-4500 335-=4500 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> t���IV:J1J•! t,�`t_�';`J ��� .�t.Il-'1i�:r'ut��`+ll''::`--:!.i r:i"T�n..i�Y':'',�I_ <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE ❑TY PIU TOTAL <br /> 1Z <br /> =r5-t t ik, 55 GALLON CIT METAL CRUM X52.170 I $5 .16 <br /> MIXED MIX-FID DR",j Vi L +rntiH.1�1' ?25.fJt] <br /> , u <br /> MS MANIFEST r-RA FuR &.AD Mi1N SY PF C'- iC;MAN;FFS• 1 $25.00 l $25.00 <br /> ,�3�;7rh•I f __ <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NOT/-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> CiOua:iC�'-='='I:d� vvo a1z; AGCvsm Nl,i fi2ig-r; 5,1,ri itLdr: D <br /> DRUMS PIU: r EMPTY DRUMS: FACILITY: BSC J <br /> n �b IRT" <br /> I <br /> GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIAT BOX) <br /> By signing below I hereby certify that: 1 1 <br /> {Waste oil generator/customer MUST check ONE of the following three boxes} <br /> #01 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is LESS than 1,0(10 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 11 <br /> the Information I have provl ded about this waste is Incorrect <br /> 0 #z[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.l <br /> have provided proper documentation to World Oil Environmental Services to rebut the presumption that this waste was mlxed with other hazardous waste.I agree to accept She addilional <br /> charges for the disposal of this waste If the Information I have provided about this waste Is Incorrect <br /> 0 #3)This waste Is from a tank which reflects waste all from household"dMt•yourself”(MY)and/or conditionally exempt Small quantity generator(CESOG)sources.To the hest of my <br /> knowledge,the only waste oil contained In my DIY/CESOG collection tank is soley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil <br /> from other sources.l agree to accept the addltlonal charges for dlspusaI of this waste if the inlormatlon 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 deferm[ned to be economically practicable and that I have selected the <br /> practicable method of treatment,storage,or d[spa sat currently available to me which rat nimlzes the present and future threat to human Ilfe and tha environment. <br /> This individual signing in the space set forth below on behalf of customer represents and warrants Shat he/she has the authority to bind customer,that the forgoing descriptions of waste <br /> and materials are true and accurate as packaged,marked,and laheled,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 Servlce 17rder. <br /> Service Orders with an ivvvrIut4 hazardous waste manifest(either site specific or consolidated)are subleel to an EPA Fee.These fees cover the EFA pass-through fee and administratlon <br /> of the eMa /fest pr :,rs vary based on manifest type. Applicable fees will appear on your billing Involee. <br /> Customer Signature Date Driver Signature Date <br /> I ,J(11, L afizu it ef�-b4 <br /> Print Name Print Driver Name <br />