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09/14/2010 13:57 4082622206 PANDCAUTO PAGE 03/06 <br /> FORM NO.AEc003 <br /> - ---- SERVICE ORDER <br /> ~- NO. N694479 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 S_SANTA FI: AVENUE n COMPTON, CALIFORNIA 902.21 ❑ (310) 886-3400 <br /> EPA4 CADD26277036 <br /> DIXON UNION CITY CHICO <br /> 800-727-2879 888-603-8844 800-733-9043 <br /> r7 / �._, -� ONETIME PICK UP El YES or ❑NO <br /> DATE <br /> ,... � y!„� 1 RESIDENCE ❑ YES or 0 NO <br /> CUSTOMER �� <br /> BILLING ADDRESS CONTRACT CUSTOMER ❑ YES or Gl NO <br /> PLEASE PAY FROM THIS <br /> �., SERVICE ORDER <br /> PHONE. : 'r y. • .. r CONTACT '.^ <br /> CUSTOMER NUMBER <br /> 1. <br /> CUSTOMER EPA# „^'f ! �” ��C` ;' �f ,`- ;�' -'r _ AMOUNT <br /> JOB SITE ADDRESS /� ' ✓ ;. ` '� CHECK NUMBER <br /> � c <br /> '`;1 ! a 1% .� P.O.NUMBER <br /> CROSS STREETS CASH RECEIVED <br /> (AMOUNT) <br /> NOTES; COMMODITY L"1J r) <br /> HALIDES \ �� ` P.P.M. <br /> p;'-NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED OILS)STATE CODE 221 <br /> *NO PLACARDS REQUIRED" <br /> ❑ NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)STATE CODE <br /> *NO PLACARDS OR MARKINGS REQUIRED` NEXT SERVICE DATE <br /> ❑ OTHER DRUMS DRUM SIZE <br /> MANIFEST NO. <br /> 'r"I `` r f '� .:�)= NO,OF GALLONS w <br /> DRIVER .�-.-�� •'F ?RUCK NO.&RT, _=c.�- <br /> ❑ USED OIL AND GASOLINE FILTERS <br /> ❑ SA RECYCLING, 33210 western Avenue,Union City,CA 94587 1-510-487-9277 <br /> Q ALTERNATE FACILITY <br /> DESIGNATED TSDF.- CI ASBURY ENVIRONMENTAL SERVICES•2549 Scot Avenue•Chico,CA 95923•CAL0008?-7844 <br /> ❑ ASBURY ENVIRONMENTAL SERVICES-CHICO 11,LLC•1618 W.5th St.,Chico,CA 95928•CA0980694103•(800)733-9043 <br /> ❑ ASBURY ENVIRONMENTAL SERVICES-FORTUNA•200 Dinsmore Dr.,Fortuna,CA 95540-CAI.930256136•(800)733-9043 <br /> ❑ BAKERSFIELD TRANSFER INC. •1620 E.Brundage Ln.•Bakersfield,CA 93307•CAL000282598-(661)377-0308 <br /> ❑ D/K DIXON•7300 Chevron Way•Dixon,CA 9562.0•CAT080012602•(707)693-6008 <br /> 2—DEMENNO/KERDOON•2000 N.Alameda Street-Compton,CA 90222-CAT080013152•(310)537-7100 <br /> ❑ EVERGREEN ENV.•4139 N.Valentine Ave. •Fresno,CA 93722•CAD982446882-(510)795-6400 <br /> ❑ RAMOS ENVIRONMENTAL•1515 S.River Road•W-Sacramento.CA 95691 •CAD044003656•(916)371.5747 <br /> ❑ ALTERNATE FACILITY <br /> USED OIL,USED ANTIFREEZE AND OILY WATER WASTE STREAMS ARE Thls Is to certity that the above named ortities are properly cfasslfitd,described, packaged,marked <br /> RECYCLED AT OUR SISTER COMPANY DEMENNO/KERDOON THE And labeled,and are In proper condition for transportation,according to the applicable regulations of <br /> LARGEST RECYCLER OF USED OIL IN THE WESTERN UNITED STATES. the Department of Transportatlon. ��-•--� <br /> •1 HEREBY CERTIFY THAT I HAVE NOT MIXED THIS WASTE WITH ANY <br /> OTHER WASTE,THAT TI4E TOTAL HALIDES ARE LESS THAN 1000 P,P,M.; <br /> AND THAT THE WASTE DOES NOT CONTAIN ANY P.C.131S.. CUSToMIER 6icaNATURE DATE <br /> •1 FURTHER AGREE TO ACCEPT THE ADDITIONAL CHARGES FOR LEGAL X <br /> DISPOSAL IF THIS WASTE IS OVER 1000 P.P.M.TOTAL HALIDES, OR <br /> CONTAINS ANY PC_B'S- PRINT NAME <br />