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SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004 B(REV 1=7) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> -888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H <br /> 1-80G-974-4495 <br /> p <br /> I'T <br /> D E TRANSPORTER EPA#CAD028277036 <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY -F—HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> Vi , <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 /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED' STATE CODE <br /> OTHER: <br /> DESIGNIATEDTSDF: 1 22 <br /> ALTERNATE TSCIF: <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 classirred,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 41)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 /> 0#2)1 have not mixed any of Me 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 tank which collects waste oil from household-do4t.yourself'(DIY)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 solay from DIY andlor CESQG sources.I have not mixed this waste oil with any other hazardous waste or <br /> .sete oil from other...rose.I agree to accept Me additional charges for disposal of this waste if 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 /> 0") 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 I have determined to be economically <br /> 4cficable 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 Me best waste management method that Is available <br /> me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />