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FOR SERVICE CALL' SERVICE ORDER rORM140 AExMi$-llRfll1W71 <br /> DIXON OFFICE <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> FFIESNt] <br /> 559-498-0240 _IF 111, <br /> ds — <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 TRANSPORTER EPA#CAD028277036 <br /> P <br /> P <br /> E <br /> D <br /> f <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 REC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/WXED 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 PN: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to cartily that the waste described above Is properly classified,described,packaged,marked and labeled,and is In proper condition for transportation,according to applicable State <br /> end federal regulationsfly signing below I also hereby certify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑ at I I trews not mixed any of the-sate described above with any other hazardous waste,the total halide content is LESS mart 1,000 ppm,and the waste doss not contain any PCBs.I have <br /> complied with the requirements of the apphcabla California used oil management regulations to determine this Is Idol 1 agiae to accept the additional charges for the disposal of this waste <br /> if the Information I have provided about this waste is Incorrect <br /> D N211 have Lot mtned any rat the waste deaedbed above with any other nazardous waste,the total halide content is GREATER than 1,000 ppm,and the waste aloes not contain any PCs$ I <br /> have provickab proper documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the addibonal charges <br /> for the disposal of this waste if the information I have provided about this waste is incorrect <br /> 031 This waste is from a tank which coltriet■waste oil from household"do-ihyoumeir(DIY)andlor conditionally arempt small quantity generator iCESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIYt CESQG collection tank Is sofey from DIY andfor CESdG sources I have not mixed this waste oil with any other hazardous waste or <br /> waste rad from other source&t agree to accept the additional charges ter disposal of this waste It the information I have provided abotil this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box,) <br /> p 04l If I am a large quantity generator.I certify that I have a program in Place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,of dlspotal curaently available to me which minimizes the present and future threat to human lite and <br /> the environmen l;Cu,it 1 am a emelt quantity generator.I have made a good faith effort to minimize my waste generation and select the best waste management method that is available <br /> to rite that I can afford <br /> Customer Signature Date Driver Signature Date <br /> Print Drivers Name <br />