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' f <br /> FOR SERVICE CALL: SERVICE ORDER� <br /> DIXON OFFICE ; •y " u FORM NO AESOU-B(REV 1010n <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE r'•,' — <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 /> N , . . a 1-310-886-3400 . <br /> TRANSPORTER EPA#CAD028277036to <br /> -�" "•°S" <br /> E <br /> D <br /> T <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 /> y <br /> . :, we rl�•J,Ysd�a. � <br /> i Y rg' .r <br /> TOTAL <br /> CASHREC'D: 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 /q r t 1 •, <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> DRUMS PN: - 1 """ EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify Mal the waste described above is properly classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable Stale <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 ap 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 /> D#211 have not mixed any of Me 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.1 <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 Me additional charges <br /> for Me disposal of this waste It the Information I have provided about this waste ie incorrect <br /> n#J)This waste is from a tank which collects waste oil from household'do-itryourself'(DIV)andlar conditionally exempt...If quantity generator 10ESGG)sources.To Me beat of my <br /> knowledge,the only waste oil contained in my DIYI CESOG collection tank is soley from DIY andlor CESOG sources.I have not mixed this waste oil with any other bazardous waste or <br /> waste oil from other sources.I agree to accept Me additional charges for disposal of this waste if Me Information I have provided about this weals is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 1)se) If I am a large quantity generator,I Conry that 1 have a program In place to reduce Me volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and Met I have selected Me practicable method of Vestment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> Me environment;Or,if I am a small quantity generator,I have made a good farm effort to minimize my waste generation and select Me best waste management method that Is available <br /> to me Met <br /> tIIcan afforda� <br /> /.'l:fn...t' +•. -.,L�•'x>d"�.' ,�'_' �f�a fL,. •.:..fit{ aF <br /> Customer Signature Date Driver Signature Date <br /> Print Name —� Print Drivers Name <br />