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FOR SERVICE CALL: SERVICE ORDER FORM NO.WOES004-B(8/18) <br /> DIXON OFFICE ASBURY ENVIRONMENTAL SERVICES, DBA <br /> 1-800-727-2879 SERVICE ORDER NO. <br /> FOR ACCOUNTING CALL: CMORLDOIL <br /> 562-231-1550 <br /> ENVIRONMENTAL SERVICES. <br /> s 7300 CHEVRON WAY,D ou,CA 95620 <br /> H <br /> I t:, : 1-800-727-2879 <br /> P <br /> P WWW;WORLDOILCORP.COM <br /> E TRANSPORTER EPA#CA0028277036 <br /> T <br /> O <br /> CUSTOMER* PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER.TAKEN BY HALIDES <br /> X <br /> DATE REQUIRED DATE.ENTERED NEXT SERVICE DATE CUSTOMER EPA# BILL of LADING/MANIFEST <br /> � S <br /> PART# DESCRIPTION QTY UNiT PRiCE QTY P/U TOTAL <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: 4-4 ' <br /> ALTERNATE TSDF: a.. ; <br /> r <br /> DRUMS P/U: 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 ppin,and the waste does notcontain any PCBs.I have <br /> complied with the requirements of the applicable California used oil management regulations td 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 1,6N 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 incorracf <br /> ❑#3)This waste is from a tank which collects waste oil from household"do-ft-yourself'(DIY)and/or conditionally exempt small quanthy.generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIV/CESOG collection tank Is soley from DIY and/or CESOG sources.I have not mixed this waits 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 /> (Ali generators/customers MUST read the following text <br /> 1 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 /> prectieable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human INS 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 /> r <br /> Service Orders with an associate�{�azardous waste manifest(elthersite spaoHic or consolidated)are subject to an-EPA Fee.These fees cover the EPA pass-through fee and adminlebation <br /> of the eManifest program. The�ffaes vary based on Manifest type Applicable fees will appear on your billing.invoiee, <br /> Customer,-Signature Date Driver Signature Date <br /> Print Name Print Driver Name <br />