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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON-OFFICE <br /> 7-4SBURY FORM N0.AES004B(REV IW7) <br /> SERVICE ORDER NO. <br /> 559-4980240 <br /> yCH/COOFFICE = e ''� '4t"1 <br /> 800-7339043 E C E <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> (�r�wEnCA' ANE WORKS 1-31x666-3400 JUL 1 12016 <br /> P7" f tAR)1 ROAD TRANSPORTER EPA#CAD028277036 MAXIM t'RAt'IE WORKS• PAfRE.(.(* <br /> 13 E --_- - IO III£%pfd <br /> T Si:)Ca{TCiPl CA 95206 ENVIRONMENTAL HEAL <br /> 0 (91!x) 452.306-, DEP W TX 7 757: ` <br /> 2$1 t at71•t 71^>f3 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> MA,`48C12 s <br /> 915 � J�f E'Ik/EGARCIA Lakilxia <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# <br /> MANIFEST# <br /> tr.. <br /> PART# DESCRIPTION <br /> QTY UNIT PRICE QTY P/U TOTAL <br /> 09 USeb OIL A(40 GASOLINE FILTERS <br /> W-CITP4 -65 GA.1-CIN 0(r 1-C}p 0Rtlhl Id�EC 1ttQI71 (.IEDi <br /> ! . <br /> -' SO OILY SOURS PER C1rti.eM <br /> C a Slrw,ety. <br /> CASH RECD: TOTAL <br /> CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USEDOIL/MIXED 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 /> SA RECYCLING: 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> DRUMS_PIU: EMPTY.DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> The <br /> is is is certify that the waste described above is properly classified,described,packaged,marked and labeled,and Is in proper condition far transportation, <br /> tl federal regulations.By aigning below I also hereby certify that: according to applicable Seale <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑#1)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,000 <br /> nn,and the <br /> complied with the requirements of the applicable California used oil management regulations to determine this Is true.I agree to accept the add t o al ctharges net contain any PCBs.I have <br /> if the information I have provided about this waste is incorrect gas for Ne disposal of this waste <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 imi umentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other bazartlous waste.)agree to accept the additional charges <br /> forme disposal of this waste if the information I have provided about this waste is incorrect <br /> 0 0.11 This waste is from a tank which collects at. it from h....held"do-it-younelr(DIY)and/a,conditionally exempt small <br /> quantity G)sources,To the of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is Soley from DIY anchor CESQG sources.I have not mixed th isnerator waste ii wiitth any other hazardous waste or <br /> waste oil from other sources.I agree to accept me additional charges for disposal of this waste if Ne Information I have provided about this waste is Incorrect <br /> (All generators/customers MUST read the following text and check the associated box. <br /> ❑##1 If I am a large quantity generator,1 certify that I have a prugre m ace to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> the Practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize.the present and future thrsallo human life and <br /> a <br /> to that m n afford, <br /> am a small quantity generator,I have made a good faith Won to minimize my waste generation and select the best waste management method That is available <br /> Gustoryinif Signature Date <br /> Data XDriverSignature Date <br /> Print Name G.KJ /�•.._ <br /> Print Drivers Namw <br />