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FOR SERXIqLC4j-L: - -SERVICE ORDER <br /> DIXON OFFICE v RkAf4 , ,�ESptu.F Ir;cv,1,0' <br /> 1-800-7-ASBURY _ _ SERVICE ORDER NO. <br /> FRESNO = = —— <br /> 550-495-0240 s = _= _ • <br /> _ e <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> p { <br /> E ' <br /> D <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> r <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTYUNIT PRICE QTY PIU TOTAL <br /> REC EIVE <br /> f J � <br /> FEE 7 2016 <br /> ENVIRONMENTIL <br /> _.HZA T (T TOTAL <br /> CASH RECD` CHECK# PLEASE PAY FF THIS HIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED OILS)*NO PLACARDS REQUIRED* STATE CODE 221 <br /> NON-RCRA"Ha2ARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)-NO PLACARDS REQUIRED- STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 33210 Western Avenue, Union City,CA 94587 1-510-487-9277 <br /> i <br /> DRUMS PIU: Z EMPTY DRUMS: FACILITY: t BSG <br /> GENERATOR WASE CERTiFICATICN <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 belcw I also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> 0 01)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 /> d the information I have provided about this waste is incorrect <br /> ❑X21 1 have not mixed any of the waste described above with any other nazardous 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 /> p 03)This waste is from a tank which collects waste oil from household"do-it-yourselr,(DIY)andlor conditionally exempt small quantity generator(CESQG)sources.To the fleet of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is soiey from Div and/or CESQG sources I have not mixed this waste oil with any other hazardous waste of <br /> waste oil from otner sources.I agree to accept the additional charges for disposal of this waste 4 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 /> IN s41 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 /> p?ecticable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future thastWJiuman life and <br /> the-erwironment;Or,if 1 am a s"ll quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management methO that is available <br /> to me ulafjl can afford. `•` !l -'_,/' " <br /> /0 � •,' 4 `���,�lt J P�i�� �l �i(!//t 1 t t ,,.1���:�-"'r%�f :�� (j1�t_%,+P/i <br /> Customer Signature �/ 'y Date mer 5 gnature- Date <br /> Print Name <br /> Print Drivers Name <br />