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FOR SERVICE CALL' <br />DIXON OFFICE <br />1-800-7-ASBURi' <br />(Mr�� <br />800-733-9043 <br />' 6610E ORDER <br />OCT 14 2015 �-_ - <br />s ave <br />yWkONME INIR <br />! EAI.: DEPART"A . <br />ASBURY ENVIRONMENTAL SERVICES <br />'1300 SOUTH SANTA FE, COMPTON, CA 90221 <br />1-310-886-3400 <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. AES004-8 (REV 10107`, <br />SERVICE ORDER NO. <br />L5 <br />CUSTOMER # PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES F <br />DATE REQUIRED DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER EPA # <br />MANIFEST # <br />PART # <br />DESCRIPTION <br />QTY <br />UNIT PRICE <br />QTY P/U TOTAL <br />TOTAL <br />CASH REC'D: CHECK # PLEASE PAY FROM THIS SERVICE c km:-_;- <br />WASTE DISPOSAL INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OILIMIXED 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 />SA RECYCLING: 33210 Western Avenue, Union City, CA 94587 1-510-487-9277 <br />DRUMS PN: EMPTY DRUMS: FACILITY: BSC <br />GENERATOR WASTE CERTIFICATION <br />PLEASE CHECK THE APPROPRIATE BOX <br />This is to certify that the waste described above is property classified, described, packaged, marked and labeled, and is in proper condition for transportation, according to applicable Stat. <br />and toderal regulations. By slgning below I also horohy certify that: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />❑ #1) 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 nol 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 />D #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 <br />have provided proper documentation to Asbury Envhonrnental Services to rebut the presumption Ilial 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 />El ii This waste Is from a lank which cnllects waste oil from household "do-ityourself" (DIY( and/or conditionally exempt small quantity generator (CESOG) sources. To the beat of my <br />knowledge, the only waste ail contained in my DIYI CESQG collection tank Is soley from 01Y andler CESQG sources. I have not mixed this waste oil with any other hazardous waste or <br />waste oil from other sources. I agree to accept the additional charges for 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 />❑ #4) If I am a large quantity generator. I certify that I have a program In place In reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />practicable and that 1 have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human lite and <br />the environment; Or, if I am it small quanfity genarator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is available <br />to me that I can afford. <br />Customer Signature Date Driver Signature Date <br />Print Name <br />Print Drivers Name <br />