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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004-6(RFV 10107) <br /> 1-800-7-ASSURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1-888-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> P <br /> T <br /> f <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# 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 /> (1"T 1, <br /> N(J, <br /> HA 1 <br /> TOTAL <br /> CASH REC'D: CHECK# <br /> 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 PIU: 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 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 /> 11 101)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 /> compiled with the requirements 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 /> 0#2)1 have not mixed any of the waste described above with any other riazardous waste,the total halide content is GREATER than 1,000 plent,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#3)This waste is from a tank which collects waste oil from household"do-it-yourself'IDLY)andlo(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 soley 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 /> 0#4) 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 I 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 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 1,Can afford. <br /> Customer Signatuid- Date Driver Signature Date <br /> Print Name Print Drivers Name <br />