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IMPERIAL TRUCK WASH <br />2142 W. YOSEMITE AVE <br />MANTECA, CA 95337 <br />(209) 239-8111 0--L rn - • w CASH REC'D: CHECK # <br />I r"-I <br />!DRUMS P/U: EMPTY DRUMS: FACILITY: ESC <br />WASTE DISPOSAL INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) <br />OTHER: <br />DESIGNATED TSDF: <br />ALTERNATE TSDF: <br />Cross Streets: OLD ACCT IMP067 Account Manager Samuel Read <br />STATE CODE 221 <br />STATE CODE <br />SERVICE ORDER <br />ASBURY ENVIRONMENTAL SERVICES, DEA <br />WORLD OIL <br />ENVIRONMENTAL <br />7300 CHEVRON WAY, DIXON, CA 95620 <br />AND REPAIR JAZZ 1-800-727-2879 <br />WWW.WORLDOILCORP.COM <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. WOES004-B (8/18) <br />I <br />, SERVICE ORDER NO. <br />1 N4088673 i i <br />IMPERIAL TRUCK WASH AND REP, <br />2142W YOSEMITE AVE <br />IVIANTECA, CA 95337 <br />(209) 239-8111 <br />FOR SE13:-ACE CALL: <br />DIXION OFFICE <br />1-800-727-2879 <br />FOR ACCOUNTING CALL: <br />562-231-1550 <br />'CUSTOMER # PURCHASE ORDER # 1ROUTE # i TRUCK # CONTACT NAME ORDER TAKEN SY HALIDES <br />I CER-86I <br />I <br />i <br /> <br />1MP072 ! --- - MANJET SINGH .arodriquez <br />t/DATE REQUIRED s DATE ENTERED i NEXT SERVICE DATE CUSTOMER EPA # BILL of LADING/ MANIFEST # <br />1 1 9/15/2022 i CAL000368693 <br />PART # ! DESCR !;--IONk I QTY UMT PRICE Or? P/13 TOTAL <br />TRA TRANSPORTATION <br />TRKW, TRUCK WASHOUT <br />: VACUU VACUUM DISPOSAL - NON <br />, <br />' ' <br />: BATCH iA <br />7. <br />-HAZARDOUS WASTE LIQUIDS <br />, , . <br />I , i <br />1 <br />4 <br />120 <br />$125.00 <br />$105.00 <br />$0.95 tC,173 <br />TOTAL <br />$125.00 , <br />$420.00 <br />$1,140.00 , <br />GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br />By signing below ! hereby certify that: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />#1) I have not mixed any of the waste described above with any other hazardous waste, the tote! 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 ! have provided about this waste is incorrect <br />.3 a2 I have not mixed any of the waste described above with arty other hazardous waste, the total halide content is GREATER than 1,000 ppm, and the waste does not contain any PCBs. <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 />L..1 #3) This waste is front a tank which collects waste oil from household "do-it-yourself (DIY) and/or conditionally exempt small quantity generator (055.03) sources. To the best of my <br />knowledge, the only waste oil contained In ray DlY/ CESOG collection tank is soley from.bly 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 />(An generators/ customers MUST read the following-text <br />I certify that have a program in place to reduce the volume and toxicity of waste generated to the degree i have determined to be economic*precticable and that I have selected the <br />praoticable method of treatment, storage. or disposal currently available to me which minimizes the present and future threat to human life adttie.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 materiels 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 tees cover the EPA pass-tough fee and administration <br />of the eMenitest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice. <br />Clr'btomer Signature Date <br />\NI \ ii-Pj6Q1 id--- <br />Orr;en+ et:" <br />I / <br />Driver Signature Date <br />ineT;.5 <br />I