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•DIXON OFFICE SERVICE ORDER • <br /> FORM N0.AES001B(REV 10107) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1 -98-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H .,. ,.:.. -.. 1-800-974-4495 <br /> P <br /> E - -- TRANSPORTER EPA# CAD028277036 <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# MANIFEST# <br /> t,;i f-31�. frYi't4�j i f: <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> C. SHRECD: 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: <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587 (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 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 /> 0 #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 Me requirements of the applicable California used oil management regulations to determine this Is true.1 agree to accept the additional charges for the disposal o1 this waste <br /> If the information 1 have provided about this waste is incorrect <br /> 0#211 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 Me additional charges <br /> for Me disposal of this waste if the information I have provided about this waste is incorrect <br /> 0#3)This waste is from a tank which collects waste oil from household"dolt-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIV CESQG collection tank is Soley from DIV and/or 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 Me additional charges for dieposal of this..start 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 /> O #a) 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 /> r --able and that 1 have selected Me practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> increment;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 nie Mat I can afford. <br /> / <br /> Customer Signature Date Driver Signature Date <br /> Print Idamo P.l..s n.l.,e.c Id.,..... <br />