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FOR 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 <br /> FOR ACCOUNTING CALL: N3423257 <br /> 562-231-1550 GWORLDOIL <br /> ENVIRONMENTAL SERVICES- <br /> S 7300 CHEVRON WAY,DIXON,CA 95620 <br /> H Q AND M, DBA TRACY CHEVROLET 1-800-727-2879 <br /> P 3400 AUTO PLAZA WAY WWW;WORLDOILCORP.COM 3400 AUTO PLAZA WAY <br /> CA 9530 . TRANSPORTER EPA#CAD028277036 <br /> TRACY, TRACY, CA 95304 <br /> o (209) 835-4500 (203) 835-4500 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> QAN001 G ER-86 JOHNIBEATRIZ smartinez <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATIE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> 1'1/17/2020 CAL000330423ZZ /'�. <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> OFNC NON CONFORMING OIL FILTERS 1 1,65,06 $165.00- <br /> OF-DR OIL FILTER DRUM REPLACEMENT- NO CHARGE 1 $0.00 , $0.00 <br /> ABSO R ABSORBENT PADS BOXES 5 $12.75 $68,85 <br /> 25 <br /> BATC! <br /> TOTAL <br /> CASH REC'D: CHECK# _•' <br /> WASTE DISPOSAL INFORMATION <br /> NON=RCRA HAZARDOUS WASTE'LIQUID(USED OIUMIXED OILS) .;STATE CODE 221 <br /> NON=RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: . NON-R:RA HA?ARDOIJS WA.STF soi in(Fil TFRS rONTAINING 011) State code'"I <br /> DESIGNATED TSDF: YES MANAGEMENT, INC.,6500 US HIGHWAY 95,YUMA,AZ 85365 <br /> ALTERNATE F: <br /> Cres tree : wo n/c Account Manager:,Sam Read' <br /> DRUMS P/U:' Y 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 /> ❑#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 /> 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.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 /> ❑#3)This waste Is from a tank which collects waste oil 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.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 I 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 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 labeled,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 Service Order. <br /> Service Orders with an associated hazardous waste manifest(either site specific or consolidated)are subject to an EPA Fee. These fees cover the EPA pass-through fee and administration <br /> of the eManifest gram. T sese fee�sed on Manifest <br /> type. Applicable fees will appear on your billing invoice. <br /> wsto ignature F-Pate/ river Signature T <br /> rl <br /> a <br /> /Print Name- Arintiver Name <br />