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PWb <br /> CE CAI L: SERVICE ORDER <br /> N OFFICE FORM NO.AEsn04-a(RFV 10ro7) <br /> 1-800-7-ASBUR� SERVICE ORDER NO. <br /> UNION CITY OF�Ii:,E <br /> 1-888-603-8844 = I <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ;,.SBJRY EN,JIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> i `' -1-310-886-3400 <br /> F c>r TRA.NSPORI ER EPA#CAD028277036 !4 if a i <br /> E #`3 Ai <br /> D <br /> Ti iw <br /> O =#i.^ <br /> CUSTOM Et # i PLtf2CHASE{ORDER# RC's!I.EE# TR! K At CONTACT PlAME ORDER TAKEN BY HALIDES <br /> DATE REQUIREE3 DATE ENTERED NEXt SE7PA15t DATA CUSTDIMER EPA#A� MANIFEST# <br /> PART# DESCRIPTION an, UNVT PRICE QTY P/U TOTAL <br /> i <br /> f <br /> i.it!I TGG c� <br /> � {E <br /> I <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> WASTE DISPOSAL iNFORMATION <br /> NOM-RC#tea HAZARDOUS WAST E, LIQUID(USED OIUMIXED 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;-SDF: <br /> SA REC:YC4 INC,i, 33210Western Avenue. Union City,CA 94-387 1-510-487-0277 <br /> DRUMS PIU: EMPTY DRUMS:___ FACILITY: ___i3SC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify!rat.ir,%-,aata�,_,s Jbed ahoy+ is v: perly classified,descrlced,package",marker and'abeled,and is in proper condition for transportation,according to applicable state <br /> and federal regulaBnni 2•:yignirr helow I iisc'aerahy",ertify <br /> (Waste coil generator/customer MUST check ONE of the following three boxes) <br /> D #1)1 have not mixed any of the waste descrihed above with arg oche,hazardous waste,the total halide concert is LESS tl:ar+,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 hax e pro,ided about this waste is incorrect <br /> C#2)1 have not mixed an;of the,%aste 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 clocumentat:or.to Asbury Environmental Services to rebut the prseumption that this waste eras mixed with other hazardous waste.1 agree to accept the additional charges <br /> for the disposal of this waste if the information i have provided about thio,waste is incorrect <br /> C#3)This waste is from a tank which colieets waste oil from househole"do-it-yourself',Dlv)andfor 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 ardor CESQG sources.I have not mired this waste oil with any other hazardous waste or <br /> waste oil from other sources.I agree to accept the additional charges fo•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 /> C#4) If I am a targe quantity generator,i certify that I have a program in r lace to reduce t:-e volume and toxicity of Haste generated to the degree 1 have determined to be economically <br /> practicable and that I nave selected the practicable method of treatment,storage,of disposal currently availabie 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 ane select the best waste managemeno rtlethod that is available <br /> to me that I can afford. <br /> Customer Signature Dare Driver Signature. Date <br /> Print Name -^- - �Jv _ ^—�- Prirt nriuers Name <br />