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SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004-6(REV 101i <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE _ __- <br /> 1-888-603-8844 = _ <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> S <br /> ri 1-800-974-4495 <br /> -? <br /> p (-a1rri 11 o-..11{Ji 1..,!41'3F P,dl, i Sil'41.�R 3T <br /> E TRANSPORTER EPA# CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> i to uij, , <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH RECO: 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: {ftl�f. ,+19 L! 1'i3td '!ia , •1 roti ham. t/. 17<Iti7 ..41 <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PN: EMPTYDRUMS: 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 inapplicable State <br /> and federal regulations.By signing below 1 also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> CI 11111 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 1 have provided about this waste is incorrect <br /> 0 e211 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-I agree to accept Me additional charges <br /> for Me disposal of this waste if the information I have provided about this waste is incorrect <br /> 0 i This waste is from a tank which collects waste oil from household"do-it-yourself-(DIV)andlor conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIYI CESQG collection tank is coley 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 Me additional charges for disposal of this waste if Me 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 wq If 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 1 have determined to be economically <br /> rtacticable 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 /> .me 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 /> to me Mat 1 can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />