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FOR SERVICE CALL: SERVICE ORDER FORM NO.AESOo4-s(REV 1010n <br /> DIXON OFFICE <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE _— <br /> 1 --4-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE,COMPTON, CA 90221 <br /> S 1-310-886-3400 <br /> H <br /> I ,ii I L:,i�� r u"^ ��:' = TRANSPORTER EPA#CAD028277036 <br /> p 1011;E <br /> D <br /> T is lit l /f. <br /> Q {ci <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ,1J I °�; b a '' a *AF0i,. J*, <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> 00 <br /> i.}S i`;i, i1° f (• it It „I.Fti I! ),I- C;k;r'?:1i�t_ --"'y <br /> TOTAL <br /> CASH RECD: 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 /> DESIGNATEDTSDF_ 5 °, 1,iX fP'g '{^t. ;Fk'k'Ri d YE Cr1X(§iRa r3 Y +5 i' �r' 3^n Ogx Lti t1'k 11?u3 s` <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City,CA 94587(510)487-9277 <br /> DRUMS PN: EMPTY DRUMpiy .. FACILITY: BSC <br /> (f,-. 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 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 /> D':#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.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 this waste <br /> If the information I have provided about this waste is incorrect <br /> ❑#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.1 <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 1 have provided about this waste is Incorrect <br /> D#3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIV)andlor conditionally exempt small quantity generator(CESQGI sources.To the bast of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is soley from DIV and/or CESOG 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 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 /> Q#dl 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 /> I 'able and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize.the present and future threat to human life and <br /> I Aronmenl;Or,if I am a small quantity generator,I have made a good faith short 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 />