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SERVICE ORDER • <br /> SAN DIEGO OFFICE FORM NO.AES004-B <br /> 1-800-748-5744 SERVICE ORDER NO. <br /> NORTHERN OFFICE <br /> ' 800-7-ASBURY <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> HLOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICE� <br /> P 1-800-974-4495 1-8GO-748-5744 I-1100-7-ASBURY <br /> P <br /> E <br /> D TRANSPORTER EPA#CAD028277036 <br /> T <br /> ",i <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN U77 HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> -1 <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> va? <br /> TOTAL I <br /> ,-ASH RECID: 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 /> !, �,i -��-t tt �� �p!14 ir I ' 't <br /> DESIGNATEDTSDF: ! � <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PIU:— 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 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 comfy that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑ #11)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 /> 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 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./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 vm,de is from.tank which collects waste oil from household-do-o-yourself"(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the beat of my <br /> k--.I.dg.,the only waste oil contained in my EM CE SQG collection tank is solay from DIY andfor C ESoG 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 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 /> 04) If I am.[.,go quantity generate,I certify that I he,..program in ptit..to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> icti cable and that 4 have selected the practicable method of treatment,storage,or disposal currently available to me which Minhourto,the present and future threat to human life and <br /> environment;or,if I am a small qu entity generator,I have made a good faith effort to minimize my waste generation and$&]act the best waste management method that is available <br /> LO me that I can afford. <br /> If <br /> x; <br /> Customer Signature Date Driver Signature Y Date <br /> Print Name Print Drivers Name <br />