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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO AES004.81REV 8 151 <br /> 1-WO-7-ASBURY _ SERVICE ORDER NO. <br /> FRESNO <br /> 559.498-0240 - v — <br /> CHICO OFFICE <br /> 800.733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-885-3400 <br /> a TRANSPORTER EPA#CAD028277036 <br /> p <br /> E <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 ©TY PIU TOTAL <br /> TOTAL <br /> CASH REC`D: 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,UQUID(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 PN: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify Ihat the wade described above is property classlfted,described,packaged,marked and labeieu,and is in proper condition for Rransportation,according to applicable State <br /> and Federal regulations.By signing below I also hereby certify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 01)1 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 wasle dues riot GwItain any PCBs,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 this information I have provided aboul this waste Is incorrect <br /> Q 92)l have not mixed any of the waste described above with any other haLwdcui waste.the lutea halide content is GREATEN than 1,000 ppm,and the waste doe%not cont-m any PCBs.1 <br /> have provided proper documentation Io Asbury Environmental Serwlces to rebut the presumplion that this waste was mused with other hazardous waste.I 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 /> 0 11131 This waste is from stank which collects weals oil from household-do�it-yourselr(Diy)andlor conditionally exempt Small quantity generator ICESQG)sources.To the best al my <br /> knowledge,the only waste oil contained In my DIY!CESpG collection tank is soley from DIY andler CESOG sources I have not mixed this waste oil with any other hazardous waste m <br /> waste oil from otner 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 /> 0 94) if I am a large quantity generator,I tartly that I have a program in piece 10 raduu the volume and losicily of waste generated to the degree I have determined la be economically <br /> practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which mmimita l the present and future threat to human life and <br /> the environment;Or,it I■m a small quantity generator,I have made a good faith effort to minimize my wools generation and select the best waste management method that Is available <br /> to Rte that I Call afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />