Laserfiche WebLink
FOR SERVICE CALL: SERVICE ORDER <br /> FORM NO AES004-8 iRFV S+I51 <br /> DIXON OFFICE <br /> 1-804-7-ASSURY SERVICE ORDER NO. <br /> FRESNO - `Y <br /> 550-498-0240 _+ <br /> GNlGO OFFICE M <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H 1-310-886-3400 <br /> I TRANSPORTER EPA 0 CAD028277036 <br /> P <br /> E <br /> D <br /> T <br /> 0 <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 /> TOTAL <br /> CASH RECD: CHECK# <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: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> SA RECYCLING 23285 Eichler, Ste. E,Hayward,CA 94541 323-921.478A <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to Certify that the waste described above is property ciasarhed,dasenhed,packaged.masked and labeled,and is in proper condition for transportation,according inapplicable State <br /> and federal regulations.By signing below t also hereby certify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑ as]1 have not mixed any of the waste described shove witti any other lutardous 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 ort management requialrons to determine this Is true I agree to accept the additional charges tot the disposal of this waste <br /> it the informshon 1 have provided about this waste is inconeci <br /> ❑x211 have not mixed any of ilia waste described above with any other narardoas waste,the total halide content is GREATER than 1,000 ppm,and the wants does not contain any PCBs 1 <br /> hare provided proper documentation to Asbury Environmental Services to rebut the presumption that this-sate was mixed with other hazardous waste I agree to accept the additional charges <br /> for the dlaposal of this waste it the intormation l have provided about this waste is incorrect <br /> ❑ 01)This waste is from s tank which collects waste oil from household-do iLyourself'(DIY)sndior conditlenalty exempt snlad quantity ganefalor(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY1 CESQG collection tank is Way from DIV andlar CESOG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste oil from other sources-t agree to accept the additional chargee lot disposal of Una 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 /> ❑ 04) 111 am a large quantity generator,I certify that I have a program In place to reduce the volume and toxicity of waste genefaled to the degree I have determined to be nconomically <br /> practicable and that I have selected the procticabie method of treatment,storage,or cbsposat currently available to ma whleh m nimiles the present and future threat To human life and <br /> the environmanr,Or,if I am a&man gnamity generator.I have made a gond faith effnrl to minimize my wawa generahnn and select the best waste management method that is available <br /> 10 me mat I can afford <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />