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FOR SERVICE CALL : SERVICE ORDER DIXON4FFICE FORM NO. AES004-B (REV 10/07) , 850 T-gSBURY SERVICE ORDER NO. " AllESNO - 559498,0240 - gCHICO OFFICE 800- 733.9043 ASBURY ENVIRONMENTAL SERVICES s 1300 SOUTH SANTA FE , COMPTON , CA 90221 H k4AMW ` RA Iw *C >f' KS 1 -310-886-3400 P � MAR ) k`„� Rt �, TRANSPORTER EPA # CAD028277036 +"i9rnEFur t,• t ) ! N: t rC.} 5 � ` ! , iG., P E n p PO Iii n ;X4 CUSTOMER # PUR ;HASEDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDESf) FVE� DyATE REQU;IIRED DAED NEXT SERVICE DATE CUSTOMER EPA # J MAd NIFEST # F � . t�? .w ' *i jl '4 , .�.`E¢3,x�}'�7�1 .k� N+�S¢21 'j r ~'"1 { arm Lf�rJ { Irt � .J ! PART # DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL 011„ 4 } "1 °ry{ ll II1 , 11 ; PL w WIN I TOTAL CASH RECD: CHECK # PLEASE PAY FROM THIS SERVICE ORDER WASTE DISPOSAL INFORMATION NON-RCRE1 HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) *NO PLACARDS REQUIRED* STATE CODE 221 NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) *NO PLACARDS REQUIRED* STATE CODE OTHER: DESIGNATED TSDF: ALTERNATE TSDF : SA RECYCLING: 33210 Western Avenue, Union City, CA 94587 1 -510-487-9277 DRUMS PN; EMPTY_ DRUMS : - FACILITY: BSC - GENERATOR WASTE CERTIFICATION PLEASE CHECK THE APPROPRIATE BOX 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 and federal regulations. By signing below I also hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) #1 ) I have not mixed any of the wastedescribed above with any other hazardous waste, the total halide content is LESS than 1 ,000 ppm, and the waste does not contain any PCBs. 1 have complied 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 if the information I have provided about this waste Is incorrect ❑ #2) 1 have not mixed any of the wastedescribed 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 have provided propeFdocumentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste. I agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is incorrect p43) This waste is from a tank which collects waste oil from household "do4t-yourself' (DIY) and/or conditionally exempt small quantity generator (CESQG) sources. To the best of my knowledge, the only waste oil contained in my DIY/ CESQG collection tank is Soley from DIY and/or CESQG sources. 1 have not mixed this waste . oil with any other hazardous waste or 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 (All generators/customers MUST read the following text and check the associated box.) ❑. #4) If I am large quantity generator, 1 certify that I have a prograrg h place to reduce the volume and toxicity of waste generated to the degree I have determined to he economically practicable and that I have selected the practicable method of treatrroknt, storage, or disposal currently available to me which minimizes the present and future threat-to,human life and 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 ma0agement method that is available to me that I can afford. J .K J?/' Custom Signature Date Driver Signature Date R � k` a 1F ) t '(,'s. EJd1Y Print Name Print Drivers Name