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FOR SERVICE CALL! SERVICE GIRDER <br /> DIXON OFFICE IORd NO AESWB iPFV 1010r <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> FRESNO > <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 /> H 1-310-886-3400 <br /> P TRANSPORTER EPA#CAD028277036 <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 RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> WON-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 to certify that the waste described above is properly classified-described,packaged,marked and labeled,and Is in propat condition for transportation,according to applicable State <br /> and federal regulations.By signing below i also hereby certify that <br /> (Waste oil generator/customer MUS-r check ONE of the following three boxes) <br /> d Nil I have not milled any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,DW ppm,and the waste does plot contain 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 aecapt the additional charges for Rte disposal of this waste <br /> it the informallort I have provided about this waste Is incorrect <br /> U 62)1 have not mixed any of the waste doscnbed above with any other hazardous waste,the total halide content is GREATER than I,000 ppm,and the waste does not cortain any Pees I <br /> have provided proper documentation to Asbury Environmental Services to rebut The presumption that this walla was mixed with other hazardous waste.I agree to accept the addtttonal charges <br /> for the disposal oh this waste It the informalicn I have provided about this waste Is Incorrect <br /> C 03i This waste Is from a tank which collects waste oil from household^do-ihyoweelr(DIY}andlw conditionally exempt small quantity generator tCESOG)sources To the best of my <br /> knowledge,the only waste oN contained In my DIYi CESOG collection tank is splay from DIY andior CESQG sources I have not mixed this waste oil with any other hazardous waste or <br /> waste ai from other sources.I agree to accept the additional charges for disposal o/this waste If the information I haw provided about this waste is Incorrect <br /> (All generators/customers MUST read the following text and check the associated box,) <br /> T7 NII If I am a large quantity generator,I certify that I have a program in place to reduce the volume and loxieny of waste generated to the degree I have determined to be sconomlcally <br /> practicable and that I have selected the practicable method of treatment,storage,w disposal currently available to me which minimizes the present and future lh+eat to human life and <br /> The environment;Or,if I am a small quantity generator.I have made a good faith effort to minimize my waste generation and select the best waste management melhod that Is availabis <br /> 1.me,that I can atloid. <br /> Customer Signature Date Driver Signature Date <br /> Drint Name Print Drivers Name <br />