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FOR SERVICE CALL: <br /> stir <br /> SERVICE ORDER <br /> DIXON OFFICEFORM NO Atscoaa(PFV'0107 <br /> 4 <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE �„- <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 /> M '< " ;.. 1-310-886-3400 k- f wa r ..r. �,_:•. <br /> TRANSPORTER EPA#CAD028277036Is <br /> E <br /> G <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXTSERVICEDATE I CUSTOMEREPA# MANIFEST# <br /> PART# DESCRIPTION ff QTY UNIT PRICE QTY PIU TOTAL <br /> Arc <br /> ( <br /> TOTAL <br /> CASH RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <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: it, <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> if <br /> DRUMS PN: ^"• ''� EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to carefy that the waste described above is property classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable stale <br /> and fail regulations.By signing below I also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> D 01)1 have not mixed any of Ne 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.1 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 GRrFTER than 1,000 ppm,and the waste does not contain any PCBs.I <br /> have provided proper documentation to Asbury Environmental Services to .but the presumpthm that this...to was mixed with other hazardous waste.l agree to accept the additional charges <br /> for Ne disposal of Met waste 11 the Information I have pzovided about this waste is incorrect <br /> G#]I This waste Is from a lank which collects waste of from household"do it-yours er'(DIY)endlor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowleoge,the only waate it contained N no,DIYI CESOG collection tank is soley from OIY amber CESOG source¢.I have not mixed this waste oil with any other hazardous waste or <br /> ..at.oil from other sources.I agree to accept Na additional charges for or sposal 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 /> Q#JI If I am a large quantity generator,I certify that I have a program in place to reduce but volume and toxicity of waste generated to We degree I have determined to be economically <br /> practicable and Nat I have selected are practicable method of treatment,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,l have made a good faith effort to minimize my waste generation and seLct the best waste management method that Is available <br /> to ma menet I can Word. <br /> CustomerSignature <br /> �y Date Driver Signature Date <br /> %y"-i �4�.�YI�Fi Itiil l' <br /> Print Name —� Print Drivers Name <br />