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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 /> 4-800-7-ASBURY <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H jjyj! LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICE ;4 0-' 1 <br /> p 1-800-974-4495 1-800-748-6744 1-800-7-ASBURY <br /> E <br /> TRANSPORTER EPA#CAD028277036 <br /> T <br /> CUSTOMER# PURCHASE ORDER# ROUTE# 1 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 PIU TOTAL <br /> 3 qA <br /> 6 <br /> TOTAL <br /> -ASH REC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> — NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS)'NO PLACARDS REQUIRED- STATE CODE 221 <br /> — NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED- STATE CODE <br /> — <br /> OTHER: , <br /> ! -,! I i a 1 71 �4� 14 11, 41 <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 property classified,described,packaged,marked..d labeled,and is in pn.pa,condition for transportation,according to applicable State <br /> and federal regulations.By signing below I also hereby codify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 #1)1 have net 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 deathbed 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 rated the presumption that this...to 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 I.incorrect <br /> ❑#3)This waste Is from a tank which collects waste oil from household (01Y)amdlor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my OW CESCIG collection tank is coley from My 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 me additional charges for disposal of this waste if the information I have provided about this waste is incorrect <br /> I (All generators/customersMUST read the following text and check the associated box.) <br /> It*4) It 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 /> -acflcable 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 ge,19,tar,lhave made a good faith effort to minimize my waste generation and select the best waste management method that is available <br /> me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />