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POR SERVICE CALL: <br />DIXON OFFICE <br />1-800.727-2879 <br />FOR ACCOUNTING CALL: <br />562-231-1550 <br />I'EF 9nY5 ttu i I I <br />4987 WEST LANE <br />S I kljk I CN,CA S14 1 <br />(209) 952-1222 <br />JCnV I. L- VI tUL.J I <br />ASBURY ENVIRONMENTAL SERVICES, DBA <br />EN\/ NMENTAL SERVICESA, <br />73( C O�DIXON,CA951520 <br />7-2879 <br />WWW.ILCORRCOM <br />T RANSPORTER EPA # CAD028277036 <br />I-UHM NU. VVU1-bUU4-t3 (0/ Its) <br />SERVICE ORDER N0. <br />N3to75r7t; <br />ORCHARD ST <br />t�e,,��MONrc�NI N,1 n�o37 <br />{SJ(7) 33443794 <br />CUSTOMER # <br />GENERATOR WASTE CERTIFICATION (PLEASE CHECK THE APPROPRIATE BOX) <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES <br />P, -P3`19 <br />CL=^ <br />PATRICK SNil"i 1-1, <br />SGI-1PDUI_ED-I <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER EPA # <br />BILL of LADING/ MANIFEST #� <br />10/:31P2019 <br />1 W2212019 <br />— CAD081662844 <br />PART # <br />DESCRIPTION <br />QTY <br />UNIT PRICE <br />QTY P!U <br />TOTAL <br />OF <br />OF DR <br />"i.c:AVE I <br />_ <br />USED METAL. 01L AND GASOLINE. FIL.I t -RS <br />OIL, FILTER DRUM REPLACEMENT - NO CIIIArRG <br />),IACk 12t-:I.F.AiL' ftil'dGu ��i`dS; T E" BATCH n¢ „i--. ...... <br />1 <br />/ <br />TOTAL <br />CASH REC'D: CHECK #i _ <br />WASTE DISPOSAL INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OJUMIXED OILS) STATE CODE 221 <br />NOWRCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) STATE CODE_-_ <br />OTHER:_-.=,k�.?hNi6Pb4-HF4Z-AP.�E96u-?ilA,:,':],.-i= ;--- <br />DESIGNATED TSDF:'YE,SMANAr FM�NC.4t501LU.5.anGHYVAY 94 YI IIvtA„Ay Rra363 q7 a"7n.c.gEi�a <br />ALTERNATE TSDF:Cron;- <br />;t <br />f11 >= 7-[iLP N1tGC�E1N 0(11111-8E= 3U C 11iG _-_= aunt bLaananer' fi to Rasa <br />DRUMS P/U(7.— EMPTY DRUMS: FACILITY:__. BSC <br />By'sl{ming boloty i hereby certlty [fiat: <br />(Waste ail generator/customer MUST check ONE of the following <br />three hexes) <br />Q on I have not mixed any of the waste described above with any other hazardous waste, the total halide content Is LESS than t,00o ppm, and the waste does not contain any pGDs.l have <br />compiled vilh the requirements of the applicobie California used all management reputations to determine this Is true, f agree to accept the additional charges for the disposal of tilts waste it <br />the infarmallon I have provided about this wants Is Incorrect <br />D 021 have not mixed any of the waste described above with eAV other hazardous t'welq the total halide content Is GREATER than 11000 ppm, and the waste does not contain any PGBs.I <br />have provided proper documentation to World 011 Environmental Services to rebut the presumption that flits wnoto was mired with other hazardous waste.) agree to nacepl the additional <br />charges for ilia disposal of this waste If Ilia inforntnilen I hove provided about this waste Is Incorrect <br />U n) This waste is from a lank which collects wants All front household"do-ll-yourself"(DIY) amUor conditionally exempt small quantity generator(CESQG) sources. To the boar of my <br />knowledge, the only visite off contained In my DIY/ CESQG collection lank is si ley from DIY and/or CESQG sources I have not mixed this waste ort with any other hazardous wants or waste all <br />from other sources. I agree to accept the additional charges for disposal of this waste If the iltformallon I hove provided about this weals Is Incorrect <br />(Ail generators/ customers MUST read the following text <br />I certify that I have a program In place to reduce the volume slid toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the <br />practicable method of treatment, storage, or disposal currently avallable to me which mmkabea the present And future threat to human life and the environment. <br />This Individual signing In the space set forth below on behalf of customer represents and warrants that he/she has the authority to hind customer, that the forgoln dascdpgons of waste <br />d matarlals are true and accurate as packaged, marked, and labeled, are ready for transportation In accordance with applicable state and Inderal regulations, an� LIAR customer shall abide <br />frythe Standard Terms slid Conditions on tiro revarso side of this Servlce Order, <br />Service Orders with an associated hazardous waste manifest (ellhor site spaclgc or consolldatanl) Are sub act to an EPA Feo. Theso fees cover the EPA fo .s -Through tee olid administration <br />of tire Manifest program. These fees vary based on Manifest type. Applicable fees will appear on your billing invoice, <br />Customer Signature Date D ' r Signature Date <br />s <br />_----tl��-1----- <br />print Name � Print privet Name <br />