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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO AES004 B,REV&15) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240 _�- <br /> CHICO OFFICE g v <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> a TRANSPORTER EPA#CAD02827703£ <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 /> TOTAL <br /> CASH REC'D: 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 /> 5A RECYCLING: 23285 Eichler. Ste E Hayward. CA 94541 323-921-4784 <br /> DRUMS PIU: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This Is to certify that the waste descnbed above Is property classified described,packaged,marked and labeled,and ism proper condition for transportation,according to applicable Slate <br /> and federal regulations By sigNng below I also hereby certify that <br /> (Waste oil generator/k Ust mer MUST check ONE of the following three boxes) <br /> A 01)1 have not mused any of the waste described above with any other hazardous waste,the total haitde content is LESS than 1,000 ppm,and the waste does not contain any PCBs.I have <br /> compiled with the requirements of the applicable California used oil managemsnl regulabons 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 /> 1]0211 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 PCBs i <br /> have provided proper documierttalion to Asbury Environmental Services to rebut the presumption that this waste was mined with other hazardous waste I agree to accept the additional charges <br /> for the disposal of this waste it the information I have provided about this waste is incorrect <br /> D 031 This waste is from a link which collects west*Oil from household"do-it-yourself-IOIY)andlor condiuonafly esempt small quantity genaretor(CESOGI sources.To the best of my <br /> knowiedgs,the only-Flats oil contained in my DIVI CESOG collection tank Is Soley from DIY andlor CESOG sources.I have riot mixed this waste oil with any other hazardous waste or <br /> -sale as from other sources I agree to accept the additional charges for disposal of this waste it the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and Check the assodated box.) <br /> ❑ ") If I am a large quantity generator,I certify thal I have a program In place to reduce the volume and loxlcily of waste generated to Ute degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently evadable to me which minimizes the present and fulure threat to human life and <br /> the environment;Or,if I am a small quantity generatnr,I have made a good faith effort to minimize my waste generation and select the beet waste mansgemrent method Utal is avallabia <br /> to me that I can stford <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />