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•DIXON OFFICE SERVICE ORDER • FORM NO AES004B(REV 10/07) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1-888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H 1-800-974-4495 <br /> :;... . , <br /> P <br /> E TRANSPORTER EPA#CAD028277036 <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 PIU TOTAL <br /> TOTAL <br /> ASHREC'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: <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587 (510)487-9277 <br /> DRUMS P/U: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the wands 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 1 also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 #i)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 /> ❑#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 doe.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.)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 /> 0#3)This waste is from a tank which collects waste oil from household'do-ihyourselr'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the bast of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is soley from DIV andlor CESOG sources.I have not mixed this waste ail with any other hazardous waste or <br /> waste oil from other sources.I agree to accept the additional chargee 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 /> O"t If l 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 /> recticable 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 /> environment;Or,if I am a srnall quantity generator,l have made a good faith effort to minimize my waste generation and select the best waste management moth ed!that is available <br /> me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print nrivprez Nam. <br />