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. SERVICE ORDER • <br /> DIXON OFFICE Foam NO ALsooae IaEv 1 oro <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1 '3-603-8844 <br /> - ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> Hi ! Lt}1 ':.;,.;,,,; 1-800-974- 495 <br /> P �� 1 ' . I-" "T LAI lse'If <br /> E TRANSPORTER EPA#CAD028277036 <br /> T i tfCKTON, r.y1 <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 /> TOTAL <br /> CASHREC'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: 3321 D 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 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 I also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> b 41)1 have not mixed any of Me 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.t have <br /> complied with Me 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)I 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 the presumption that this waste was mixed with other hazardous waste.I agree to accept Me additional charge. <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"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,Me only waste oil contained in my DIY/CESQG collection tank is soley from DIY and/or CESQG sources.l 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 disp...I of this waste if the information 1 have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 'Q"I If I am a large quantity generator,I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> Ir able and that I have selected Me practicable method of treatment,storage,or disposal currently available to me which mini the present and future threat to human life and <br /> L Aronmenq 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 Mat I can afford. <br /> Customer Signature Date Driver Signature Date <br /> pArvr <br />