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F�is s RVIeE CALL: SERVICE ORDER <br /> ORM NO AES004-B(REV 10!00 <br /> DIXON OFFICE <br /> 1-800-7-ASBURY ---- SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240 _ <br /> CHICO OFFICE -- <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> S 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> P <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK-# CONTACT HAI'>:^IE ORDER TAKEN BY HAUDES— <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA 4 MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P0 <br /> IU TOTAL <br /> c. <br /> hGH �(CCUL�S <br /> 1 I 2 —V TOTAL <br /> CASH RECD: CHECK# PL SE f Ai` FROM THIS SERVICE ORDS <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE. LIQUID(USED OIL/MIXED OILS)'NO Pl.A..CAPGS REQUIRED* <br /> 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 /> LJ SA RECYCLING: 33210'Western Avenue,Union'City,CA 945587 1=510=487-9277 <br /> DRUMS P/U: 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 properly 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 boxes) <br /> 0 91)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.1 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)I 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.l 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 03)This waste is from a tank which collects waste oil from household"do4t-yourself'(DIY)and/or 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 soley from DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste oil from otherisources.I agree to accept the 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 /> Q#4) If I am a large quantity generator,t certify that I have a program in place to reduce the volume and toxicity of.caste generated to the degree I have determined to be economically <br /> pract cable and that 1 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 /> the 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 that I can afford. <br /> Customer Signature Date Driver Sighature Date <br /> Print Name Print Drivers Name <br />