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FSR sERricE CALL : SERVICE ORDER
<br /> DIXON OFFICE , FORM N0. AES6046 (REV 10/07)
<br /> 1-800-77ASBURY _ SERVICE ORDER NO.
<br /> FRESNO
<br /> 559498- 0240
<br /> CHICO OFFICE
<br /> 800- 733-9043
<br /> ASBURY ENVIRONMENTAL SERVICES
<br /> s 1300 SOUTH SANTA FE , COMPTON , CA 90221
<br /> tt llF a, 14 r3 a ( I > j + 1 -310-886-3400 s
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<br /> t tq-t TRANSPORTER EPA # CAD028277036
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<br /> CUSTOMER # PURCHASE ORDER # ROUTE # TRUCK # CONTACT NAME ORDER TAKEN BY HALIDES
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<br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA # MANIFEST #
<br /> PART # DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL
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<br /> CASH RECD: CHECK # PLEASE PAY FROM THIS SERVICE ORDER
<br /> WASTE DISPOSAL INFORMATION
<br /> NON-RCRA HAZARDOUS WASTE, LIQUID (USED OIL/MIXED OILS) *NO PLACARDS REQUIRED* STATE CODE 221
<br /> NOWRCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) *NO PLACARDS REQUIRED* STATE CODE
<br /> OTHER:
<br /> DESIGNATED TSDF:
<br /> ALTERNATE TSDF:
<br /> SA RECYCLING : 33*� I'0`1/ % „ ", , . . - b td87 9E77 li4d ' E t rr ` { x •( „' , " `
<br /> ier�.'X1�t�IiuSCfJlStbfi �it>,igtL :,845$7�. ;fr 1,. P; l ;.a �1, s
<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 /> [] #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 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 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 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 1 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' (DIY) and/or 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) 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 I-have determined to be economically
<br /> practicable and that I have selected the practicable method of treatment, storage, or disposal cur'antly available to me which minimizes the present and future threat to human life and
<br /> the environment; pr, -ifl- am a small quantity generator, / 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 /> Print Name Print Drivers Name
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