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FOR SERVICE CALL: SERVICE ORDER <br /> FORM N0 AES0046 iRE4'81151 <br /> DIXON OFFICE <br /> 1-600-7-ASBURY SERVICE ORDER NO. <br /> FRESNO E ^�, <br /> 559-498-0240 <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> s 1-310-886-3400 <br /> 'i TRANSPORTER EPA#CAD028277036 <br /> P <br /> P <br /> E <br /> T <br /> 1J <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 ©TY UNIT PRICE QTY P/U TOTAL <br /> ftok, / 7 <br /> TOTAL <br /> CASH RECD: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, UQUID(USED OILINXED 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 /> DRUMS PN: EMPTY DRUMS: FACIUTY: BSC <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 laboled.and is in proper condition for hanaportatim,aecotding to applicable State <br /> and federal regulations.By signing below I also hereby carhly that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> Q ai)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than t,000 ppm,and the waste does not conlon any PCBs I have <br /> complied vis lh the requirements of the applicable California used oil management regulations to determine this h true.I agree to accept the additional charges fur the disposal of this waste <br /> if the inlormatior I have provided about this waste is incorrect <br /> ❑0211 have not mixed any of the waste described above with any other nazardous waste,the 10101 halide content to GREATER than 1,000 ppm.and the waste doss not contain any PCBs.I <br /> have provided proper documenlalion to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.t 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 /> j)a3)This waste Is from a tank which collects wsale oil from household"do•IPyourseH-101Y)ander conditionally exempt small quarnity generator ICESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESOG collection tank is coley from DIY andio,CESQG sources.I have not mixed this wsale oil with any other hazardous waste of <br /> waste oil ffum other sources I agree to accept the additional charges for disposal o1 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 /> U 04) If t am a large quantity generator,I certify that I have a program In plata 10 reduce Inc volume and toxicity of waste generated to the degree I have determined tube economically <br /> practicable and that t have selected the pfactiwWilo method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> If..en iii unman 1,Or.d 1.m•smell 9u 61-y gener.tnr.I lav made a good faith effort to minimize my waste generation and select the best waste management method that Is available <br /> to me that I can afford <br /> Customer Signature Date Driver Signature Date <br /> r,__.at..__ Print Drivers Name <br />