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CUSTOMER ## <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME ' <br />ORDER TAKEN BY__T HALIDES <br />DATE REQUIRED <br />DATE ENTERED <br />NEMSE62VlCE DATE <br />CUSTOMER EPA# <br />MANIFEST# <br />PART# DESCRIPTION <br />QTY <br />UNIT PRICE <br />QTY PIU <br />TOTAL <br />:.� <br />7> <br />3 <br />.00 <br />TOTAL <br />GASH RECD: CHECK## <br />WASTE DISPOSAL INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OJUMIXED OILS) `NO PLACARDS REQUIRED" 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 />,. <br />SA RECYCLING:t ,-323-921-y ,, a <br />84 <br />DRUMS PN: ` EMPTY DRUMS: FACILITY: BSG <br />%_=N=mAi um vvAJ i t 1-tR f iFil-AI IUN <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 it1) 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 P2) 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. 1 agree to accept the additional charges <br />fo✓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) andlor conditionally exempt small quantity generator (CESQGJ sources. To the best of my <br />knowledge, the only waste oil contained in my DIV 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 other sources_ t agree to accept the additional charges for disposal of this waste if the information t have provided about this waste Is incorrect <br />(Alt generators/customers MUST read the following text and deck the associated <br />0.,#4) If I am a large quantity generator, 1 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 />practicable 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 />to minimize my waste generation and select the best waste management method that is available <br />the environment; Or, if I am a small quantity generator, I have made a good faith effort <br />to me that 1 can afford. <br />Customer Signature \ Date ' Driver Signafur`e Date <br />Print Name Pont' Drivers Name fi( <br />