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• SERVICE ORDER • <br /> SAN DIEGO OFFICE FORM NO.AES004-B <br /> 1-800-748-5744 SERVICE ORDER IN <br /> NORTHERN OFFICE <br /> 4-800-7-ASBURY <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERNOFFICE <br /> P 1 1-800-9744495 1-800-748-5744 1-800-7-AS13URY <br /> P <br /> E TRANSPORTER EPA#CAD028277036 <br /> T <br /> CUSTOMER# PURCHASE ORDER# R9UTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> .7 r� <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA#. MANIFEST# <br /> PART# DESCRIPTIQN. , QTY UNIT PRICE QTY P/QUA TOTAL <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 <br /> SCGENERATOR 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 /> ❑ 111)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.1 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 Hazard...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 the additional charges <br /> for the disposal of this waste if the information I have provided about this waste is incorrect <br /> C#31 This waste is from a tank which collects waste oil from household"do-it-yourselr'(DIV)andfor conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my 01Y1 CESQG collection tank is holey from DIY and/or 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 chargee for disposal of Mia waste it 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 /> (a#4) If 1 am a large quantity generator,1 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 /> 'i 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 general.,I have made.good faith effort to minimize in,waste generation and select the best waste management method that is available <br /> me that I.can afford. +)# <br /> Customer Signature Date Driver Signature ''yf Date <br /> J <br /> Print Name Print Drivers Name <br />