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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004-B(REV TV) <br /> 1-800-7-ASBURY _ SERVICE ORDER NO. <br /> UNION CITY OFFICE i , _ _ <br /> 1-888-603-8844 4 <br /> CHICO OFFICE <br /> 800-733-9043 �SV <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> Hz. ;i;"tii,1'i '^fi':� Yc 1-310-886-3400 <br /> P �;`s , . a 4rsK:��FxrR =z; TRANSPORTER EPA#CAD028277036 <br /> P ,315 a A!y',ERICAII �, TREE:T <br /> E <br /> D <br /> T STC� <br /> 0 , <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <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: h4- E' :x ,, I ;_ .w. - ,• t s �, <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 properly classified,described,packaged,marked and labeled,and is in proper condition for transportation,acording to applicable State <br /> and federal regulations.By signing below I also hereby 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 not 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 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 /> for the disposal of this waste if the information I have provided about this waste is incorrect <br /> C]#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 DIY/CESQG collection lank Is soley from DIY and/or CESQG sources.I have not mixed this waste oil with any o"her 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 /> `--y 44) If I am a large quantity generator,I 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 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 rtte,!hat I can afford. <br /> LI <br /> Customer Signature Date Driver Signature Date <br /> i— <br /> Print Name Print D'hvers Name <br />