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• SERVICE ORDER <br /> DIXON OFFICE FORM N0.AES004-6(REV 10107) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> .BION CITY OFFICE <br /> R88-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H 1-800-974-4495 <br /> P <br /> P <br /> E <br /> D TRANSPORTER EPA#CAD028277036 <br /> 0 <br /> 1 , <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 P/U TOTAL <br /> r ...i . ,t <br /> TOTAL <br /> 'ASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER ' <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED 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 /> 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 pm,edy 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 #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 /> 0#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 I have provided about this waste is incorrect <br /> 0#3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(C ESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY1 CESQG collection tank Is soley from DIY andfor CESOG 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 Me information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> b Md) 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 /> p'-,=cable 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 /> 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 /> me Mat I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name o.i.f n.i. __ u,..,.. <br />