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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 /> s 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> 1 1.;; , LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICE <br /> P - 1-800-974-4495 1$00-748-5744 1.800-7-ASBURY <br /> E TRANSPORTER EPA# CA0028277036 <br /> T wI I fia- , C ('h '. A-?I :r"xi I t y.:.iJ-I (! . 1`il <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> ryry <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIF/E�ST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> a <br /> i 4 i ra rlil till. Il 3.. �.! , ILI a <br /> TOTAL <br /> .:ASH RECD: 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 j <br /> OTHER: <br /> DESIGNATED TSDF: a ""'' �' ' <br /> ..a .. i y P:11M, .11 1 771, ,.,M77 a ,.,.,,,,,, <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587 (510)487-9277 <br /> DRUMS PN: EMPTY DRUMS: FACILITY: BSC <br /> GENERATORWASTE-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 certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> El #1)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 /> 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 /> ❑92)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.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#3)This waste is from a lank which collects waste oil from household"do-it-yourself'IDIY)andlor conditionally exempt small quantity generator Ie ESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY1 CESGG collection tank is soley from DIY andfor CESGG 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 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 /> 1") If I am a large quantity generator,I cerlifyffiat 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 /> •acticabte and that I have selected the-proctr able method of treatment,storage,or disposal currently available tome which minimizes the present and future threat to human life and <br /> i environment;Or,if I am a smayeiasmity generate(,1 have made a good faith effort to minimize my waste generation and select the best waste management method that is available <br /> m me that I can afford. ,. <br /> 1 l <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name d <br />