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FOR SERVICE CALL: SERVICE ORD R <br /> FORM NO AES004-B'REV 10/07) <br /> DIXON OFFICE _ <br /> 1-800-7-ASBURY — SERVICE ORDER Na <br /> UNION CITY OFFICE s — 0- j <br /> 1-888-603-8844 <br /> ASSURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H i-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> p <br /> E <br /> 0 <br /> T <br /> O <br /> CUSTOMER# PURCHASE OR ER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTE ED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> i ! <br /> PART# DESCRIPTION: QTY UNIT PRICE, QTY PIU TOTAL <br /> i <br /> TOTAL <br /> CASH RECD: CHECK PLEASE PAY FROM THIS SERVICE ORDER, <br /> WASTE DISPOSAL INFORMATION <br /> I� NON-RCRA HAZARDOUS WAST , LIQUID(USED OIUMIXED OILS)'NO PLACARDS REQUIRED` STATE CODE 221 <br /> NON-RCRA HAZARDOUS WAST , LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED* STATE CODE- <br /> OTHER: <br /> DESIGNATED TSDF:_ <br /> ALTERNATE TSDF: <br /> CFR: 33210;lwestern Avenue, U ion City, CA 94587 (510)487-9277 <br /> DRUMS PIU: EMPTY RUMS: FACILITY: SSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the waste described above is pri <br /> erly 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 he rocertify that: <br /> (Waste oilenerator/customer MUST check ONE of the following three boxes) <br /> D #1)1 have not mixed any of the waste described ab ve 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 Cali ornia 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 ncorrect <br /> D#2)1 have not mixed any of the waste described ab ve 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 documentation to Asbury Enviro mental Services to rebut the presumption that 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 rovided about this waste is incorrect <br /> p#3)This waste is from a tank which collects waste o I from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIYi C SQG 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.I agree to accept the add tional charges for disposal of this waste if the information I have provided about this waste is incorrect <br /> (All generators/ ustomers MUST read the following text and check the associated box.) <br /> D#4) If I am a large quantity generator,i certify that I ave 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 me had of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> the environment;Or,if 1 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 <br /> to me that I can afford. - <br /> Customer Signature Date Driver Signature Date <br /> Print Narita Print nrivprc Namcn <br />