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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 <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 t <br /> hltP(;.; ll.,'?- LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICI, <br /> p 1-800-974-4495 1-800-748-5744 1-800-7-ASBURY <br /> e y .i ' ),IF�' +„a;;_ <br /> 1) TRANSPORTER EPA#CAD028277036 <br /> T <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> _, f, ;t'%i t (:3, . ' . :J'-9I k. f(! •,i�':U, r , ,, / � it I �� <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U I TOTAL <br /> TOTAL <br /> —ASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS)"NO PLACARDS REQUIRED” STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED* STATE CODE_ <br /> OTHER: <br /> DESIGNATEDTSDF_ l,,i`Lta, . t , tail 9,�, qA .N4 , kA V-It Ai,. t,+ /I, <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 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 dozes) <br /> 'Q #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 /> �omplled 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 /> D 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.1 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 /> ❑013)This waste is from a tank which collects waste if from household"do-i[-yourselr'IDIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the beet of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is soley 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 charges for disposal of this waste if the information I have provided about this waste ie Incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> A#d) If 1 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 1 have determined to be economically <br /> ¢ticable 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 generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is available <br /> w me that I can afford. <br /> Customer Signature_-- Date Driver Signature Date <br /> Print Name Print Drivers Name <br />