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re- r <br /> M p _ � � . SERVICE ORDER <br /> FORM NO . AES004-A <br /> SERVICE ORDER N0. <br /> N2.. 177785 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE , COMPTON CA 90221 <br /> H i i' .:MIFR t: I- R *10Y LPR DODGE JEEP RAMOS ANGELES OFFICE SAN DIEGO OFFICE <br /> P 180 NI'; t:LE ' hoar_ , 1 -800-974,4495 1 -800-748-5744 3460 N /\GLE E RaAD <br /> P <br /> E _ ?A ( , CA 95301 TRANSPORTER EPA # CAD028277036 TRACY, CA 95304 <br /> T 10 9) 820 - 18415 ( 209) 820- 1895 <br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES <br /> PRI` 147 1 '10 ' � �� .CIikDUI _ EI� <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # MANIFEST # <br /> ail /2016 CAL000ab50 3 <br /> PART # DESCRIPTION QTY UNIT PRICE QTIY PN TOTAL <br /> USED 01L. / MI.XED OILS <br /> ) SED 0IL SFRVICE CHARGE <br /> TOTAL <br /> CASH REC ' D: CHECK # . <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: 2035 Es 15TM Street, Los Angeles, CA 90021 (800) 645-3458 <br /> DRUMS PN : EMPTYDRUMS : 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: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> IT NJ ) I have not mixed any of the waste described above with any What hazardous waste, ilio total halide content is LESS than 14000 ppm, and ilia waste does not contain ,fly PCBs . I have <br /> ioniplied with the requirements of the applicable California used all managemmll regulations to determine this Is true. I agree to accept the additional charges for the disponal of this wasto <br /> if the information 1 have provided about this waste Is incorrect <br /> ❑ 92) 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 w45to is Incorrect <br /> ❑ #3) This waste Is from a lank which collects waste oil from household " do-It-yourseir, (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 tank Is sotay 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 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 /> Q N4) If t am a largo quantity generator, I certify that 1 have a program In place to reduce Ilia volume and toxicity of waste ganaraled to Ihn Uegreo I have aetarmhrad to be economically <br /> Pfafticable and that I have seleiled the jiracticable mothod of treatment, storage, or disposal cunrently available to me which minimlzos ilia present and future throat to hwnsn Ilio mild <br /> the , envuonmorit ; Of, If I am a Pmall quahiity generator, 1 have made a good fault effort to minimize my waste generation and select the hest wj" a management method that Is avanabto <br /> tome lhol I can atford. r <br /> Customer Signature Date Driver SignatureDate <br /> Print Name Print Drivers Name <br />