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FOR SERVICE CALL: SERVICE ORDER FORM NO ALWA.BIRP4 IDM7} <br /> DIXON OFFICE <br /> 1-600-7-ASBURY > _ _ SERVICE ORDER NO. <br /> FRESNO L= - <br /> 559-498-0240 <br /> CHICO OFFICE — — - <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE COMPTON. CA 90221 <br /> S 1-310-886-3400 <br /> H <br /> TRANSPORTER EPA#CAD028277036 <br /> ii <br /> E <br /> D <br /> T <br /> n <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 /> r <br /> TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDrR <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: 33210 Western Avenue, Union City,CA 94587 1-510-497-9277 <br /> DRUMS PN: 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 proper condition for transportation,according io appllcabie State <br /> and federal regulations By slgruog below 1 also hereby earilfy that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑ all 1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than i,000 ppm.end the waste does not contain any PCBs.I have <br /> complied with the requirements of the applicable California used ad management regulations to determine this Is true-I agree to accept the acidiflooal charges for the disposal of this waste <br /> if the information 1 have provided about this waste Is incorrect <br /> 13 0211 haw not mixed any of the waste described above with any other nazafdous waste.the total halide content is GREATER than f.DW ppm,and the wale does not cont...any PCBs 1 <br /> have provided proper documentation to Asbury Environmental Sarwress to rebut the presumption that this waste was mleed with other hazardous waste I agree to accept the additional charges <br /> Oar the disposal of this waste it the information I have provided about this waste is incorrect <br /> 0 sal This w961e Is from a tank which collect*waste all from household"do 4t-yourself JUVI andinr conditionally exempt small quantity generator(CESQGI sources To the best at my <br /> knowledge,the only wsale oil contained In my DIY1 CESQG collection lank Is coley from 41Y andror CESQG■aurCa*.I have not mixed this waste oil with any other hazardous waste or <br /> waste ori from other sources-I agree to accept the additional charges for disposal of this waste If the Information I have provided about this waste 1s Incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> U lull If I am a large quantity generator.I certify that I have a program in place to reduce the volume and toxicity at waste generated to the degree I have determined to be economically <br /> practicable and that 1 have selected the practicable method of treatment,storage.or disposal currently available to me which minimizes the present and future threat to human life and <br /> the environment;.Or,if I am a small quenb.ly generator,1 have mode a good faith efforl to minimize my waste generation and select the bast waste management method that is available <br /> to me"let I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />