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FOR SERVICE CALL: M SERVICE ORDER <br /> DIXON OFFICE 0 FORM N0 AES004-B(AEV 10/07) <br /> 1-800-7-ASBURY _ SERVICE ORDER NO. <br /> UNION CITY OFFICE f,l!r <br /> 1-888-603-8844 = — <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 7`C-�14cy �C(, pt;r f.:, �#l�°�"�iu1 I 1-310-88 <br /> TRANSPORTER EPA#400 <br /> #CAi]028277036 <br /> E wY460 NAGL R!:?a"D ��� �l. I .t ROAD <br /> t�tUNDL E SEF:�t`ICE <br /> T TRACY, CA 95376 <br /> O (.'L' 3 Fr t1 TRACY, CA 953-1"11111 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> i <br /> Pot; ,' <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> .}. t .,.. <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> rEF11; <br /> TOTAL <br /> CASH RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS'WASTE, LIQUID(USED OILIMIXED 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 /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PIU: 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 /> 0 41)t have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,006 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.t agree to accept the additional charges for the disposal of this waste <br /> if the information f have provided about this waste is incorrect <br /> p#2)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 Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charges <br /> Tar the disposal of this waste if the information I have provided about this waste is incorrect <br /> 0#3)This waste is from a tank which collects waste oil from household"do-it-yourself")DIY)andlor conditionally exempt small quantity generator IGESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my OlYl CESQG collection tank is soley from MY andfor CESGG sources.I have not mixed this waste all with any other hazardous waste or <br /> waste oil from other sources.I agree to accept the additional charges for disposal of this waste if 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#4} If I am a large quant-sty generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree t have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> the environment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that Is available <br /> to me that I can afford. <br /> f . <br /> Customer Signature Date Driver Signature s Date <br /> Print Name Print Drivers Name err <br />