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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004-B(PFV 100) <br /> 1-800-7-A.SBURY _ SERVICE ORDER Np. <br /> UNION CITY OFFICE <br /> 1-888-603-8844 = <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> 1-310-886-3400 <br /> TRANSPORTER EPA#CAD0288277036 <br /> r" 4:� Ni $a F Fxepi .. �yk # ilr h l^' :113;+ <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> t-`t .'y'If <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <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: SSC <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,andis 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 #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 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 <br /> if the information I have provided about this waste is incorrect <br /> 0#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 /> for the disposal of this waste if the information I have provided about this waste is incorrect <br /> 0 431 This waste is from a tank which collects waste oil from household"do-it-yourself"(DIY)andlor conditionally exempt small quantity generator(CESQGI sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY!CESQG collection tank is Soley from DIY andlor CESQG sources.I have not mixed this waste oil 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 I 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 quantity generator,I 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 <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 beat waste management method that is available <br /> to me that r canafford. <br /> r <br /> Customer Signature Date Driver Signature pate <br /> rye . ; <br /> Print Dame Print Drivers Name <br />