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r <br /> f <br /> 40 SERVICE GALL: SERVICE ORDER �ORMNO AES004-6(REV 10107) <br /> 14,- <br /> XON OFFICE •-- SERVICE ORDER NO. <br /> `800-7-ASBURY <br /> UNION CITY OFFICE <br /> 1-888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> S 1-310-886-3+400 <br /> " TRANSPORTER EPA#CA0028277036 <br /> 'If+'i IrkfiiZla} <br /> aRfiIs1{rI a i €lies:! <br /> �-} moi 9 , 0 4 <br /> 4y�y t"-'(+1,.� M t'+i<e �.ti �L/ "��k'i <br /> } <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> MANIFEST# <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER;=PA# r <br /> PAR9# ____,:DESGR1PTiONQTY UNIT PRICE QTY PIU TOTAL <br /> sl t;tl�b 4.,[�iSOL_144 t', <br /> INVOICE # <br /> ACCT �j <br /> ACCT �121(lI <br /> ACCTA <br /> NAME TOTAL <br /> GAsxREC'D:-_ CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILlMIXED OILS)-NO PLACARDS REQUIRED* STATE CODE 221 <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOL SOLUTIONS)"Nq PLACARDS REQUIRED- STATE CODE <br /> OTHER: <br /> DESIGNATED TSDF: r <br /> ALTERNATE TSDF: <br /> CFR: 33210:Western Avenue, Union City,CA 94587(510)487-9277 <br /> F <br /> DRUMS PIU: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE 13OX <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 fallowing three boxes) <br /> D 01)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 /> ble California used oil management regulations to determine this Is true.I agree to accept the additional charges for the disposal of this waste <br /> compiled with the requirements at the applica <br /> if the information I have provided about this waste is incorrect <br /> D#211 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 /> 0 091 This waste is from a tank which collects waste oil from household"do-it-yourself'(01Y)andlor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oilcontained in my t71Y!CESQG collection tank is soley from DIY 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 /> p #41 It 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 l 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 env onment;Or,if I.am a stn'a11 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 th t I can afford. <br /> Date <br /> Customer Signature Date Driver Signature <br /> Print Drivers Name <br /> Print Name <br />