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RSERVICECALL: ! SERVICE ORDER . FORM NO AES004-B(REV 10107) <br /> DIXON OFFICE <br /> 1 800-7 AS6URY 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 /> 1-310-886-3400 <br /> H TRANSPORTER EPA#CA0028277036 <br /> P <br /> P <br /> E <br /> D <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# 1 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 /> 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 Western Avenue, Union City, CA 94587 (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 t(ansportation,according to applicable State <br /> and federal regulationsey signing below I also hereby certify that: <br /> (Waste oil generator/customer MUST"check ONE of the following three boxes) <br /> U #1)1 have not mixed-any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,060 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 1s true.I agree Yo accept the additional charges for the disposal of this waste <br /> it the infonnati on I have provided about this waste is incorrect <br /> 0#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 of 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 ID1Y)andlor 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 coley from MY andlor 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 /> 0#4) 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 t have determined to be economically <br /> practicable and that I have selected the practicahte 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 />