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FOR SERVICE CALL: • SERVICE ORDER • <br /> DIXON OFFICE FORM eo.Aesooa-e(REV a/,sl <br /> t - <br /> 1-800-7-ASBURY ( SERVICE ORDER NO. <br /> _ , �� y <br /> FRESNO 8 0240 —= �� , <br /> HICO OFFICE =E8 0 12016 <br /> -800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON,EP VININN)ENTAL <br /> 1-310-886-3400 HEALTH DEPARTMENT <br /> TRANSPORTER EPA#CAD02 7036 <br /> E <br /> D M <br /> T <br /> Q ,it 5 +r�c1 �lve.*41 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE.DATE CUSTOMER EPA# 1 ` 1 MANIFEST# <br /> // <br /> i n.. <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> / <br /> _ev. v . . - . .. <br /> -� :a's =irc+�;i•A. TOTAL i <br /> CASH RECD: 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 /> DESIGNATEDTSDF: n 'r ti '•jvc t TMti "• '' <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 2�2$�5�'Ci�lil� ,yS'te.�f,)'+1'ayN!'ari� A�dS'4Yt�' 32'3'- Y' ?$dti . ,5. . V-.r 'z'?;Mk�ry »Icy yr -.r; �., CAya:ra • <br /> - 1 ; <br /> I <br /> DRUMS PN: EMPTYDRUMS: FACILITY: SSC <br /> GENERATORWASTECERTIFICATION <br /> PLEASE CHECK THE AP-PROPRIATE BOX <br /> This is to certify that the waste descnbed 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 /> 1 have not mixed any of the waste described above with any other hazardous waste,Me total halide content is LESS than 1,000 ppm,and the waste does not contain any PCBs.I have <br /> complied with Ne requirements of Me.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)]have not mixed any of the waste descnbed above with any other hazardous waste,Me total halide content is GREATER than 1,000 ppm,and the waste does not contain any P(1Bs.I <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption that this waste was mixe.'.with other hazardous waste.I agree to accept the additional charges <br /> for Me disposal of this waste if the information I have provjdap about this waste is incorrect I• <br /> D#J)Thie waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESCG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIYI CESCG collection tank Is sotey from DIY and/or CESQG smurces.1 have not mixed this waste oil with any other hazardous waste or <br /> waste oil from other spu¢es.I agree to accept Me additional charges for disposal of this waste if Me information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> Uelf am a large quantity generator,I certify mat 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 /> :ticable and that I have selected Me practicable method of treatment,storage,or disposal cumendy available to me which minimizes the present and future threat to human life and <br /> ._e environment;Or,If I am a small quantity generator,I have made a good faith effort to minimize my waste generation and sde[sahe best waste management method that is available <br /> to me thrift can afford. !r <br /> Customer Signature Date Driver Signa turre yv1r�. ? Date <br />