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• SERVICE ORDER • <br />SAN DIEGO OFFICE <br />1-800-748-5744 <br />NORTHERN OFFICE a WN <br />1-800-7-ASBURY us Wm <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH SANTA FE, <br />i COMPTON CA 90221 <br />LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICE <br />- 1-800.974.4495 1-800-740-5144 1-800-7-ASBURY <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO, AES004-B <br />SERVICE ORDER NO. <br />CHECK# ,, F Z0M His b L RVICC C j <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OILIMIXED OILS) -NO PLACARDS REQUIRED' STATE CODE <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) *NO PLACARDS REQUIRED* STATE CODE221 <br />OTHER: <br />DESIGNATED TSDF: <br />ALTERNATE TSDF: <br />GFR: sszw western Avenue, Union City, CA 94587 (510) 487-9277 <br />EMPTY DRUMS:_ FACILITY. SSC <br />oZZevcraAIUK vVASIt CERTIFICATION <br />PLEASE CHECK THE APPROPRIATE BOX <br />This Is to certify that the waste descflbed above is property classified, described, packaged, marked and labeled. and is in proper condition for transportation, according to applicable State <br />and federal regulations. By signing below I also hereby certify that: <br />(Waste oil generator/aistomer MUST check ONE of the following three boxes) <br />0 #1)1 have not mixed any of the waste described above with any other harardous waste, the total halide content is LESS than 1,000 ppm, and the waste does not contain any PC85. I have <br />complied 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 Nis waste <br />If the imornagon I have provided about this waste is incorrect <br />D #2)1 have not mixed any of the waste described above with any other hazardous waste, the total halide content is GREATER than 1,000 ppm, and the waste does not contain any PCBs. I <br />have provided proper documentaffon to Asbury Environmental Services to rebut Ne presumption that this waste was mixed with other hazamous waste. I agree to accept the additional charges <br />for the disposal of this waste If Ne information I have provided about this waste is incorrect <br />0 0) This waste is from a Tank which collects ..at. oil from household "do-ifyourself" (DIY) andtor conditionally exempt small quantity generator (CESQG) eoumes. To the beet of my <br />knowledge, the only waste all contained in my DIY/ CESQG collection tarts is onlay from DIY andlor CESQG sources. 1 have not mixed this waste oil with any other hazardous waste or <br />waste oil from other sources. I agree to accept the additional charges for dwicural of this waste if the information I have provided abort this waste is incorrect <br />(All generators/customers MUST read the following text and check the associated box.) <br />0 #4) If I am a large quantity generator, I certify that I have a program in place to reduce me volume and toxicity of waste generated to the degree I have determined to be economically <br />practicable and that 1 have selected the practicable method of treatment, storage, o disposal currently available to mo which minimizes the present and future threat to human life and <br />the environment; Or, ir,f am a smal(quarmity, generator, I have made a good fahh effort to minimize my waste generation and select the best waste management method that is available <br />to mm that I can afford.Ir <br />j <br />Ll <br />Customer Signature Date Driver Signature Date <br />Print Name Print Drivers Name <br />