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FOR SERVICE CALL: SERVICE ORDER FORM NO AE50"RMEV IOMT <br /> DIXON OFFICE <br /> 1-800-7-ASSURY SERVICE ORDER NO. <br /> FRESNO - = _ <br /> 559-498-0240 <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> ii 1-310-886-3400 <br /> N TRANSPORTER EPA#CAD028277036 <br /> P <br /> E <br /> D <br /> i <br /> 0 <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 /> 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 to certify that the waste described above is property classified,describedpackaged,marked and labeled,and 1e in proper sondilton for transportation,according to applicable State <br /> And federal regulations.By signing below 1 also hereby certify that <br /> (Waste oil generator/customer MUST check ONE.of the following three boxes) <br /> ❑ fit)I have not nixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1.100 ppm,and the waste does not contain any PCBs.i have <br /> camplied 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 /> if the information I have provided about this waste is incorrect <br /> U 02)1 have not mixed any of the waste described above with any other nazardous waste,the total halide content is GREATER than 1.000 porn.and the waste does not contain any PC9s t <br /> have provided proper documentation to Asbury Environmental Sarvtces to rebut the presumption that this waste was mixed with other hazn <br /> ardous waste.I agree to accept the additioal charges <br /> lot the disposal of this waste if the Information I have provided about this waste rs Incorrect <br /> n 031 this.sate is from a tank which collects.4610 aI from household"do-it-yourself INYI and or conditionally exempt small quantity generator ICESQGI sources To trio boil of my <br /> knowledge,the only waste oil contained In my DIV CESOG collection tank Is solay from MY andfor CESOG sources.1 have not mixed this waste oil with any other hazardous waste a <br /> waste oil Prom other sources.I&gree 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 Next and check the associated box.) <br /> ❑84I If I am a large quantity genaralor.I certify that I have a program in place tc reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically <br /> pracllcable and that I have selected the practicable method of treatrhenl,storage,or disposal currently available tome which minimizes the present and future threat to human life and <br /> the environment;Or.a I am a small quantity generator..I have made a prod With effort to minimize my waste generation and select the best waste management method that it available <br /> to me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />