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•DIXON OFFICE le SERVICE ORDER IORM NO.AES004 B(REV 10107) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 588-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H <br /> 1-800-974-4495 <br /> p <br /> E <br /> D TRANSPORTER EPA#CAD028277036 <br /> T i!, <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFESTW_ <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> GASH REC'D; CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIIXED 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 TS0F:_1!'L L .airy, P'UAJP� L,tf 77 <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PN: EMPTYDRUMS:_ FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to codify 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 11)I have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 pare,and the waste does not contain any PCEIs.I have <br /> compiled 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 piano,and the waste does 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.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 03)This waste is from a tank which collects waste ail from household`do4t-youmelf'(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.TO the best at my <br /> knowledge,the only waste oil Contained in my DIY/CESQG collection tank is coley from DIY andfor CESQG 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 /> n") If I am a large quantity generator,I cartity,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 /> cticable 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 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 P,ir.+n,;--- Put— <br />