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y, <br /> FOR SERVICE CALL: SERVICE ORDER FORM NO.AFSNi-B(REV 10107) <br /> DIXON OFFICE SERVICE ORDER N0. <br /> 1-800-7-ASBURY <br /> FRESNO <br /> 559-498-0240 <br /> CHICO OFFICE 4 evier <br /> 800-733-9043 �`R�E <br /> ASBURY ENVIRONMENTA� S s� 6�•�� <br /> 1300 SOUTH SANTA FE,COMP ON, CA��iV <br /> 1-310-886-3400 <br /> H <br /> TRANSPORTER EPA#CAD028277036 Rv � p'c�� <br /> lit <br /> P 1 � � <br /> D YO t,fT A <br /> T <br /> O <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 I 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 OILIMIXED 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 it <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the waste described 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/customer MUST check ONE of the following three boxes) <br /> 001)1 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 /> cbmplied 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 /> if the information 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 documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous 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 /> D%]I This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)andfor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESOG collection tank is soley from DIY andlor CESOG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste oil from other sources.1 agree to accept the additional charges for disposal of this waste if the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> +�M4) 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,or disposal currently available to me which minimizes the present and future threat to human life and <br /> the environment;Or,if I am a small 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 me that I can afford. _ <br /> Customer Signature Date Driver Signature Date <br /> Print Namno Print Drivers Name <br />