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FOR SERVICE CALL: • SERVICE ORDER • <br /> DIXON OFFICE FORM NO.AES004B(REV 10/07) <br /> 1-800.7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE — — ' <'• <br /> 988-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> H 1-310-886-3400 - <br /> P ':`., t L1.1`. : -2-*. ; TRANSPORTER EPA#CAD028277036414trC1t1(:.._... <br /> E 1471. li',HOta 1 c T <br /> D <br /> T <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j 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 P/U TOTAL <br /> W+r; _ it t tj y <br /> TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> ' NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED 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: ?c r, Iiitl at. bNi6+)!',:1 WiiY lliti�i 4':w '3 3' d"i(t ,.r,it I r l , n�„ it <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487.9277 <br /> DRUMS PN: EMPTY DRUMS: FACILITY: BSC <br /> at <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 /> D #1)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 /> 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 /> 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 Ne 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 it from house held"do.it.yourseIf'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIYI CESQG collection tank is soiey from DIY and/or CESCG 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 about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> It 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 /> mticable 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 /> a environment;Or,if 1 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 Name Print nri,.rxre N.nno <br />