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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO AES004.6(REV 0/151 <br /> 1-800-7-ASSURY <br /> FRESNOxii�` SERVICE ORDER NO. <br /> 559-498-0240 <br /> CHICO OFFICE — <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> 1-310-886-3400 <br /> p TRANSPORTER EPA#CAD028277036 <br /> P <br /> E <br /> O <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# I TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# <br /> MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY Pfu TOTAL <br /> roTAL <br /> CASH RECD:- CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS 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 PIU: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is 10 certify that the waste described above is property classdied,described,packaged,marked and labeled,and is in proper condition for transportation,according io applicable State <br /> and ftderat regulations.By signing below I also hereby certify that. <br /> {Waste oil generator/Customer MUST check ONE of the following three boxes) <br /> ❑ e1)1 have not mixed any of tilt waste described above with any other hazardous waste,the total hande content Is LESS than 1,060 ppm,and the waste does not contain any PCBs,I have <br /> complied with the requirements of the appiicabie California used cid management regulations to determme this Is true.I agree td accept ilia&dddionat charges For the disposal of this waste <br /> of the information I have provided about This waste Is incorrect <br /> ❑02)l have not mixed any of the waste described above with any other nazaidous waste,the total halide content is GREATER than 1,000 ppm,and the waste dote not contain any PCBs.I <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption that this waste Was mixed with other hazardous waste.l agree to accept the additional charges <br /> for the disposal of this waste if the information I have provided aboutthis waste Is Incorrect <br /> ❑e3)This waste is from a lank which c01141c1s waste Col Ilam household"do-Il-yoursetr(D(Y)and/or conditionally exempt small quantity generator(CESOG)sources-To the best of my <br /> knowledge,the only waste oil contained In my DIYI CESOG collection tank is sotey,From DIY and/or CE5OG sources.I have not mixed this waste oil wish any other hazardaue waste or <br /> waste od From other source--I agree to accept the additional charges for disposal of this waste 4 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 /> ❑ e41 If I an,a large quantity generator,I earthy that I have a program in place to reduce The volume and toxicity of waste generated to the degree I have determined to be econom¢atly <br /> pracltcable and that I have selected the practicable method of treatment,storage,or disposal currently ava fable to me which minimizes the present and future threat to human fife and <br /> the environment,Or,It I am a&malt quantity generator,i have made a good faith effort to mintnaze my waste generation and select the best waste management method That is avaiiab <br /> to me that t can afford. la <br /> Customer Signature Date <br /> Driver Signature bate <br /> Print Name <br /> Print Drivers Name <br />