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f^ 1�5 tit <br /> FOR SERVICE CALL: SERVICE ©BOER FORM NO.AEiOD4B IRFV 10107} <br /> DIXON OFFICE -- SERVICE ORDER NO. <br /> 1-800-7-ASBURY <br /> FRESNO <br /> 559-498-0240 Or -= <br /> CHICO OFFICE j <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> s 1-310-886-3400 <br /> " TRANSPORTER EPA#CAD028277036 ' <br /> v <br /> P <br /> E <br /> O <br /> T <br /> O <br /> CUSTOMER# PURCHASE SERVICE ORDER# ROUTE# TRUCK# CONTACT NAME DATE CUSTOMER EPA# ORDER TAKEN BY MANIFEST# HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> RECEIVED <br /> �u� 2 s 2ot5 <br /> PERMITISE"OES TM <br /> TOTAL <br /> CASHREG'D: CHECK# i�L. SE F'/1Y FI'iO;1J1 lTIIS SERVICE C.)RDE <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED OILS)"NO PLACARDS REQUIRED" STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)"NO PLACARDS REQUIRED" STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> DRUMS PN: <br /> EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the waste described above is properly classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable State <br /> and federal regulations-By signing below I also 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,o0o ppm,and the waste does not contain any PCBs.I have <br /> complied with the requirements of rhe applicable California used oil management regulations to determine this Is true.I agree to accept the additional charges for the disposal of this waste <br /> if the information I have provided about this waste is incorrect <br /> 17#2)I 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 Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.1 agree to accept the additional charges <br /> 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(CESQG)sources.To tl,e best of my <br /> IY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or <br /> knowledge,the only waste oil contained in my DIY!CESQG collection tank is coley from Ds for disposal of this waste if the information I have provided about this waste is Incorrect <br /> waste oil from other sources.I agree to accept the additional charge <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> practicable and that quantity <br /> selected he practicythatle I havethod oftreatment,ram i place to d(educe t sal car ently avail ble to me whume and toxicity of waste ich h minimizes the penerated to the resent aree I nd future threat to ve determined to human life and economically <br /> the environment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and solea the hest waste management method that is available <br /> to me that I can afford. ` <br /> ---1—l— Date <br /> Customer Signature <br /> Date Driver Signature <br /> Print Drivers Name <br /> Print Name _.-. <br />