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SERVICE ORDER <br /> DIXON OFFICE • ry <br /> FORM NO.AES0044B(REV 1010 <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE - <br /> 1-888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> 1-800-974-4495 <br /> P <br /> E TRANSPORTER EPA# CAD028277036 <br /> T I _ <br /> 0 <br /> CUSTOMER# PURCHASEORDER# ROUTE# j 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 /> TOTAL <br /> -ASHREC'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 /> 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 WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This Is to codify that the waste described above is properly classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable Stale <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 /> Q #i)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 Ne information I have provided about this waste is incorrect <br /> ❑ 11 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 but 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 /> 0 113)This waste is from a tank which collects waste ail from household"do-it-yourself (DIY)andlor conditionally exempt small quantity gen orator(C ESOG)sources.To the beat 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 chargee for disposal of this waste if Ne information I have provided about this waste is Incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> ,0#a) If I am a large quantity generator.I certify that 1 have-a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> -ecficable 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 isavailable <br /> . <br /> not that i can afford. <br /> Customer Signature Date Driver Signature Date <br /> 1 <br /> Print Name Print Drivers Name <br />