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FOR SERVICE CALL: v SERVICE ORDER <br /> DIXON OFFICE FORM NO AES004E IREV 10971 <br /> 1-800-7-ASBURY — <br /> UNION CITY OFFICE _— - - — — SERVICE ORDER N0- <br /> 1-888-603-8844 <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON. CA 90221 <br /> " 1-310-886-3400 <br /> I TRANSPORTER EPA#CAD028277036 <br /> P <br /> P <br /> E <br /> D <br /> T <br /> O <br /> 1 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH REC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOS: -INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED 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 94567 1-510-487-9277 <br /> DRUMS PN: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This Is to candy that waste described above is property classified,described,ear waged.marked and labeled,ane n u,p,oper ,,ndit.,m in,tramlwnau m.accurdmg to appliubl.Stale <br /> and federal regulalloref ey signing below 1 ala.hereby(fin"Ilul: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 at)l have not mixed any of the waste daKnbed above with any nine'hazardous waste,the Solid halide content a LESS than SAW ppm,and the wash,do .not comm any PCBs I have <br /> complied wire the requirements of the applicable Cahfornia used oil management regulations to determine this Is diva I agree to accept the additional charges So,the disposal of the waste <br /> d the informaboh I have provided about this waste is incorrect <br /> 0 III 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 p..d.d proper documentation to Asbury Environmental Sol'..to .but the pasumpli.that This wart.was mixed with other hazardous waste.I Sights to accept the adiddrOnal charges <br /> for the disposal of Inis wasted the mformabm I have provided about this waste is Incorrect <br /> C a])This wastes from a tank xmILh Collects waste cm from household-do+byoundor)DIY)andlw conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waft.or contained in my DIYI CESOG Collection lank n coley from DIY andlor CESOG....Cox.I have not mixed this..at.od with any other hazard...wash o' <br /> waste oil from ether sources I agree to accept elle additional charges for disposal of this waste it the information 1 have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 0 Sial If 1 am a large quantity generator,1 certify the[I have a program In place m r.duca,the volume and toxicity of..at.generated to the degree 1 have determined to to economically <br /> practicable and that I have selected She practicable method of treatment,abrage,or deposal currently available do me which minimize.the present and forum threat to human tars and <br /> the enHr.nmen.Or,if 1 am.small quantal,generator,1 have made a y.od faith often io mimmd.my wore g.darelion and 1.1.0 int best waste man.gement metnad that Is available <br /> 1.me that l can."old <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />