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FOR SERVICE CALL: . SERVICE ORDER • <br /> DWON OFFICE FORM N0.AES004B(REV 10107) <br /> 1 800-7-ASBURY _ SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240 <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON, CA 90221 <br /> " sa,!lCSi:;d3 3,">lAY j}F;'1�', I, 1-310-886-3400 <br /> ast a( 11�; �4,1;q.., TRANSPORTER EPA#CAD028277036 11,517 ,r, <br /> E '. MARKET av'' <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA#, I MANIFEST# <br /> PART# DESCRIPTION QTY i I UNIT PRICE QTY P/U TOTAL <br /> :>J <br /> �T,`. ,I1 }71 h [. <br /> TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROM HIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS)'NO PLACARDS REQU RED' STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACA(t S REQUIRED- STATE CODE <br /> OTHER: <br /> fa <br /> DESIGNATED TSDF: f .4I I4 `'0' <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 certify that the waste described above is properly classified,described,packaged,marked and labeled,antl is m proper condition for transportation,according to applicable State <br /> and federal regulations.By signing below I also hereby certify that <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 19411)l 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.I have <br /> c4mpllad 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 /> iI information 1 have provided about this waste is Incorrect <br /> G#311 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.1 <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other's hazardou s waste.I agree to accept the additional charges <br /> for the disposal of this waste if the information I have provided about this waste is Incorrect <br /> p#0)This waste Is from a tank which collects waste oil from household"do-ibyoumelr'(DIY)and/or conditionally exempt small quanthy generator(CESOG)sources.To the best of my <br /> knowledge,Na only waste oil contained in my DIY/CESOG collection tank Is soley from DIY and/or CESOG sources.I 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 disposal of this waste If the information I have provided shot I Ola waste is Incorrect <br /> (All generators/customers MUST read the following text and ch Ills I k the associated box.) <br /> /#4) If I am a large quantity generator,I comity that l have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> racticable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimiz'eq tit present and future threat to human life and <br /> the environment;Or,it am a small quantity generator.I have made a good faith effort to minimize my waste generation afiq select thle bdsaste management method that is available <br /> to me Nat I can afford. i 4 YYY <br /> 19 <br /> Customer Signature Date Driver Si n' ture "'Date <br /> Print Name ,P Drirslame� -r " <br />