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SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004 9(REV lOtDT) <br /> 1-800-7-ASBURY • SERVICE ORDER N0. <br /> UNION CITY OFFICE <br /> -888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> 1-800-974-4495 t Ji <br /> P <br /> E <br /> TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> 9." ixIj 1,0 6 <br /> CUSTOMER# PURCHASEORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> 1 jI,fit I', <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> ,;ASH REC'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 /> NONACRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED' STATE CODE <br /> OTHER: <br /> DESIGNATEDTSDF: Uik iviiti $dkiv, !_il 7-res li, 777477-7777 <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 caddy 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 codify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0#1)1 have but mixed any of the West*described above with any other hazardous waste,the total halide content is LESS than 1,000 porn,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 /> 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 porn,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 waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESOG)source..To the beat of my <br /> knowledge,the only waste all contained In my DIY1 CESOG collection tank is coley from DIY andlor CESOG 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 West.I.incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> (1#4) If I am a large quantity generator,I codify 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 /> actic.ble and that I have selected me 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 /> ,o me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />