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FOR SERVICE CALL: SERVICE ORDER FORM NO AES004-B(REV 1010T DIXON OFFICE 1-800-7-ASBURY SERVICE ORDER NO. UNION CITY OFFICE = _ e— N 1 .41 1 t t' 1-888-603-8844 CHICO OFFICE 800-733-9043 ASBURY ENVIRONMENTAL SERVICES 1300 SOUTH SANTA FE, COMPTON. CA 90221 S 1-310-886-3400 H f kACY FORD MER URY / STAN H'ItR ,NSPORTER EPA#CAD028277036 P 1500 AUTO} PLAZA : :04.. AUTO Pi_ Ale. E MO NTHL Y y,X(1 ONLY T 1RACY', CA9'G5e 95376 f � �, � CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES 2.:4 i 1_i'+'.1 1`. 1 1 l f ',? i t f ! YJA Y N F f'[)rd } n DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# r] i 1, {x PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL 5a- c/ 55 GALLON C/ i ME i Ai 4i#iilrvl t `t :`-)N1i: �ltIF, M L X.t. , 1.1 F X D F U I`L.S PER O RM1 TOTAL CASH RECD: CHECK# �' PLEASE PAY FROM THIS SERVICE ORDER WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED OILS)'NO PLACARDS REQUIRED` STATE CODE 221 NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED' STATE CODE OTHER: DESIGNATED TSDF: ALTERNATE TSDF: SA RECYCLING: 33210 Western Avenue, Union City, CA 94587 1-510-487-9277 DRUMS P/U: EMPTY DRUMS: FACILITY: ! , iJ`; BSC GENERATOR WASTE CERTIFICATION PLEASE CHECK THE APPROPRIATE BOX This is to certify that the waste described above is properly classified,described,packaged,markea and labeled,and is in proper condition for transportation,according to applicable State and federal regulations.By signing below I also hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) ❑ #1)t 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 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 if the information I have provided about this waste is incorrect ❑#2)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 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 for the disposal of this waste if the information I have provided about this waste is incorrect ❑#3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)andior conditionally exempt small quantity generator(C ESQG)sources.To the best of my knowledge,the only waste oil contained in my DIYf CESQG collection tank is coley fr9m DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal of this waste if the information 1 have provided about this waste is incorrect (All generators/customers MUST read the following text and check the associated box.) ❑#4) If I am a large quantity generator,I certify that I have a progt,am in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically 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 the environment;OF,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 tome that II Caioatron:l Customer Signature Date Driver Signature Date t D,;-+Al—