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FOR SERVICE CALL: SERVICE ORDER <br /> I ORM 40 AL500491fE"r tN7'i <br /> DIXON OFFICE <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> FRESNO _ <br /> 559-498-0240 s <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON.CA 90221 <br /> S <br /> H 1-310-886-3400 <br /> P TRANSPORTER EPA#CAD028277G36 <br /> P <br /> E <br /> D <br /> Y <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 P1U TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUKXED 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 /> Lj SA RECYCLING: 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> DRUMS PAP EMPTY DRUMS: FACILITY: BSC- <br /> GENERATOR <br /> SCGENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the waste described above is property classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable Slate <br /> and federal reguietions.ey signing below I also hereby certify that. <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 11 Oil I 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 PCes 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 /> it the information I have provided about this waste is incorrect <br /> 11 ata 1 have not mixed any of the waste described above with any other nazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCs* t <br /> have provided proper documentation to Asbury Envlronmentaf Services to rebut the presumption that this site was mixed with orher hazardous waste f egret to accept the additional charges <br /> for the disposal of this waste if the infnrrnabon I have provided about this waste is incorrect <br /> 0 Mil This waste Is from a tank wtrtoh collects waste oil from household-do-it-yourself-IDIYI andior conditionally exempt small quantity generator ICESDGI sources.To the best of my <br /> knowledge,the only waste of contained In my DFYI CESOG collection tank is soley from DIY anchor CESQG sources I have not mixed this-seta oil with any other hazardous waste at <br /> wale oil from other sources.1 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 /> ❑MAI 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 frealment,storage,or disposal currently available to ria which minimizes the present and future threat to human life and <br /> the envlronrnanl:Or,If I ani a small quantlty generetoh.t have made a good ftnth eflvrt to mmhm+za my,waste generation and select the beat waste management method that is available <br /> to ina that I can afford. <br /> - <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />