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FOR SERVICE CALL: SERVICE ORDER FORM NO. WOES004 B(S/ ) <br /> _DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> i ,00-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: WORLD 0!L <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES,M <br /> H 7300 CHEVRON WAY, DIXON,CA 95620 <br /> H <br /> 1 1-800-727-2879 <br /> P <br /> P <br /> EWWW.WORLDOILCORP.COM <br /> ' <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER # PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDE <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST# <br /> PARI # DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> CASH RECD: CHECK#_ TOTAL <br /> � <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS) STATE CODE 221 <br /> NDN-RCRA HAZARDOUS WASTE, LIQUID(ETHYLENE GLYCOL SOLUTIONS) STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: _ <br /> ALTERNATE TSDF: <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 /> J#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 /> J 02 1 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 /> J#3)This waste is from a tank which collects waste ail 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❑IY 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 to 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 Indivfduaf 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 program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />