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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO AI Rlacyland <br /> 1-800.7-ASBURY SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240 >_ <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> IS 1300 SOUTH SANTA FE. COMPTON. CA 90221 <br /> H 1-310-886-3400 <br /> a TRANSPORTER EPA#CAD028277036 <br /> p <br /> E <br /> D <br /> T <br /> O <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 /> 03 <br /> TOTAL <br /> H REC'D: CHECK PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> S 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 /> SA RECYCLING: 33210 Western Avenue. Union City, CA 94587 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 rarely that His waste described above Is property classified,dascrilood,packaged,muked and labeled and is In propel condition for ban.ponalion,according to applicable Slate ' <br /> and federal regulations By algmng below I also hereby codify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 all I have not mised any of the waste deschbed above with any other hwinduos waste,the total htlide content i•LESS than f ON ppm,and the waste does not ren ihn any PCBs.I have <br /> complied with fire requirements of the applicable California used oil management regulahona 1.downtime this la in.. I agree 1..,call the audit...I charges Ion the dlapoul of this..at. <br /> if the Intormatton I have prodded about Mie wall.is Incorrect <br /> 0 0211 have not mood an,of(h.waste des.Abed above wort any other maid...saute,Me total halide ronn,nl is GREATER than 1,000 poor,and the waste dour..1 comm any PCBs I <br /> have provided proper documentation no Asbury Environmental$ ,vlces to rebut the presumption that Mie waste we*need with other huardeu. weal. I agree to accapl Mead o,.W charuee <br /> I.,the disposal of Mi...at.Il the Infomwbon I have provided all the waste 1.Incorrect <br /> 0 031 This wa.te 1.from a trek which collects waste rel from household"do-n-yo ueelr (01Y)and/or conditionally exempt.mil qumhry gmin.lor(CESGG).Durres To the bear M my <br /> knowladga,the only waste od contained In my Dlyl CESOG collection lank 1a soley from NY and/or CESGG emnce..I have not m,.ed the,wean,o0 with any other haeardou.warts or <br /> waste oil from in.ao in,th. t pros to accept the additional charge.for disposal of M,.Warned the mrorout ien I have provided so..,lble weals Is mcorn,I <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> D sa) If I am is large quaintly generates,I cantly that I have•program In place to educe the velums and ferocity of waste pi of rated to the degree I have determined to be eccoroo lly <br /> practicable and that I have selected Me ow c.ble method of beaMn,nt.storage,o,disposal currently available to me which moomil the present and future threat to human life and <br /> the environment:or.if I am is small quantity Whmtor.I have made a rood fatlh ei to nnmmae my waste generation sold select the Mat waste man rgamenl method that is ava,lahe <br /> 1.me Mal I can.".oil <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />