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FOR SERVICE CALL: <br />DIXON OFFICE <br />1-800-7-ASBURY <br />FRESNO <br />559-498-0240 <br />CHICO OFFICE <br />800-733-9043 <br />AAAirfietitA AtnQ*"1wk <br />Is A434Wsrui <br />li <br />T �ili ' ifajf4 (—A <br />0 I t,#f ill V I I <br />SERVICE ORDER <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH SANTA FE, COMPTON, CA 90221 <br />1-310-886-3400 <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. AES004-9 (REV 8115) <br />.SERVICE ORDER NO. <br />CUSTOMER # <br />PURCHASE ORDER # <br />ROUTE#j <br />TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE <br />DATE <br />CUSTOMER EPA # <br />MANIFEST <br /># <br />PART# DESCRIPTION QTY <br />UNIT PRICE QTY PIU <br />I TOTAL <br />TOTAL <br />CASH RECD: CHECK # <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: 2tM Eichler, Ste: E. Hajvyard. CA 9454f' 323-9?t ` g bI4 tEfi iii it *4Af 4RiS: t:« tw: ... <br />DRUMSP/U: EMPTY DRUMS: FACILITY: BSC ' <br />GENERATOR WASTE CERTIFICATION <br />PLEASE CHECK THE APPROPRIATE BOX <br />%This is to certify mat oue waste described above is properly classified, described, packaged, marked and labeled, and is in propo <br />proper condition for transportation, according to applicable Stale <br />A� antl federat regulations. By signing below I also hereby certify that: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />#1) I have not mixed any of the waste described above with any other hazardous waste, the total halide content is LESS than 1,000 ppm, and the waste does not contain any PCBs. 1 have <br />complied voth 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 provmed h.IA this waste is Incorrect <br />0 #211 have not mixed arty of the waste deet ribed above with any other haeardous waste, the total halide content is GREATER than 1,00(1 porn, and the waste does not contain any PCBs. I <br />have provided proper documametso t Ip Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazartlous waste. 1 agree to accept me addimonal charges <br />for the disposal of this waste if the mformafion I have provided about this waste is incorrect <br />0 03) This waste is from a tank which collects waste oil from bousehold "do-igyourvu,H`4DIY) andlor conditionally exempt ...If quao0ty generale, (CESQG) sources. To me best of my, <br />knowledge, the only waste oil continued in my Lim CESQG collection tank is soley from DIY andlor CESQG sources. ) have not mixed this ...is it with any other ha[ardous waste or <br />waste oil from amen sources. 1 agree to accept the additional charges for disposal of this waste if Ne information I have provided about this waste is incorrect <br />(All generators/customers MUST read the following text and check the associated box.) <br />0 #a1 It I am a large quantity generator, 1 carbly Nat I have a program in place to reduce the volume and toxicity or waste generated to the degree I have determined to or, ecenomlcade <br />practicable and that I have selected ma practicable method of treatment, storage, or disposal currently available to me, ado he minimize} the present and future throat to human fife and <br />the environment; Or, if 1 am a small quantity generator, i have made a good faith efrortlo minimize my waste generation and elect too best wastafnanagement marked that is available <br />to ma, mat 1 can afford. l <br />Y -t <br />Customer Signature Date Driver Signatu Date <br />Itc _ <br />Print Name Print Drivers Name <br />