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FOR SERVICE CALLS � SERVICE ORDER � FORM NO AES004-B REV10m7 <br /> DIXON OFFICE <br /> 1-800-7-ASBJfZY -- SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1-888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> S 1-310-886-3400 <br /> M TRANSPORTER EPA#CA0028277036 <br /> P <br /> P <br /> D <br /> T .. <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# 'T RUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> I� <br /> I (4 <br /> E <br /> E <br /> TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <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 /> CFR: 33210'tVestern Avenue, Union Ci4f, CA 94587 (51€x)487-9277 <br /> DRUMS PIU: EMPTY DRUMS: FACILITY: <br /> 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 voxes) <br /> ❑ #1)I have not mixed any of the waste described above with any other hazardous waste,the tots#halide content is�LESS than 1,000 ppm,and the waste does not contain any PCBs.I have <br /> complied with tlie`hquirements 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 /> ❑92)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content Is GREATER than 1,400 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 charge! <br /> for the disposal of this.waste if tate information 1 have provided about this waste is incorrect <br /> ❑#3)This waste is from a tank which collects waste oil from household"do-it-yoursett"(DIY)andfor conditionally exempt small quarrhty generator(CESOGI sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY1 CESQG collection tank is soley front DIY andlor CE50G 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 /> (Ail generators/customers MUST react the following text and check the associated box.) <br /> ❑ 94) It 4 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 tim 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 />