Laserfiche WebLink
FOR SERVICE CALL: SERVICE ORDER frJRM NO AE5f)48IaFV taxer <br /> DIXON OFFICE <br /> 1-800-7-ASBURY �— SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240va <br /> ` <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 /> M <br /> P TRANSPORTER EPA#CAD028277036 <br /> P <br /> E <br /> T <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 FF;ONI FWF; SERVICE ORnrt's <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILRNIXED 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 1-610-487-9277 <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 proper condition for transportation,according to applicable Stale <br /> and federal regulations.By signing below I also hereby tertify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> O st)1 haws not mixed any of the waste described above with any other hazardous waste,the Intel halide content is LESS than 1,000 ppm,and the waste does not contain any PCBs i have <br /> compiled with The requirements of the applicable C*hfomia used oil management regulations to determine this Is true I agree to accept the additional charges for the disposal of this waste <br /> d the information 1 have provided about this waste Is Incorrect <br /> p a2)1 haws not mixed any of the waste described above with any other nszardous waste,the total halide content is GREATER than 1,000 ppm,and the waste does not contain any PCBs I <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous wants I agree to accept the additional charges <br /> tot Bre disposal of this waste 11 the Information 1 have provided about this waste is incorrect <br /> ci s3)This waste is from a tank which coftects waste oil from household"do-41-younaff`1DIY 1 andlor conditionally exempt small quantity generator TCESOG)sources.1ro the best of my <br /> knowledge,the only waste oil contained in my OIYf CESOG collection tank is soiay from DIY andfor CESOG sources.I have not mixed this waste oil with any other hazardous waste of <br /> waste oil from other sources.I gea to accept the additional charges for disposal of this wsale it 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 /> ❑ sal 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 haws determined to be economically <br /> practicable and that I have selecled the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threatto human life and <br /> the environment:Or,If I am a small quantity generator,1 have made a good farth effort to minimize my waste generation and select the boot waste management method that to available <br /> to me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />