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FOR SERVICE CALL-1— n `FOR ORDER ' <br /> D/XOIV OFFICE sa 4F FORM NO.AES004-B(PEV 10/0 <br /> rM <br /> SERVICE ORDER NO. <br /> - - <br /> UNION CITY OFFICE <br /> RECEI <br /> 1-888-603-8844 <br /> CHICO OFFICE41 <br /> JAN 14 2011 <br /> 800-733-9043 <br /> �. <br /> ASBURY ENVIRONMENTAL SERVICES '� <br /> e 1300 SOUTH SANTA FE, COMPTON, CAIRM14ONMENTAL HEALTH <br /> S 1-310-886-3400 PERMIT/SERVICES <br /> TRANSPORTER EPA#CAD028277036 <br /> 00 KA <br /> l <br /> D ' ro� a <br /> 1.64, A <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> F_ <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> ,It, <br /> wu: °..ep 3 _ sur,� �r'aa y J{ g.� k <br /> TOTAL <br /> CASHREC'D: CHECK#. PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE,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 /> ALTERNA 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 properly 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 hereby certify that: s,RS 04 <br /> `°`� <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 not contain any PCBs.I have'`` <br /> complied with the requirements of the applicable California used oil management regulations to determine this Is true.1 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 /> ❑#2)]have not mixed any of the waste 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 documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charges <br /> `a. for the disposal of this waste if the information I have provided about this waste is incorrect <br /> ❑#3)This waste is from a tank which collects waste oil 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 CESQG collection tank is Soley from DIV 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 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,1 certify that I have 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 method 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 I 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 Name Print Drivers Name <br />