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FOR SERVICE CALL' SERVICE ORDER FORINO tF1004-gIRFV 10!07, <br /> DIXON OFFICE <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> FRES40 - - <br /> 559-498-0240 _ <br /> 'ICO OFFICE - --- <br /> uL)0-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON. CA 90221 MAR 2 8 2016 <br /> 1-310-886-3400 <br /> H TRANSPORTER EPA 1Y GAD028277036 <br /> P ENVIRVNMG1VT'r� <br /> P <br /> ED U177,W Ti i 71Cp7A!?7-7.ar•_s <br /> T <br /> 0 <br /> CUSTOMER# PURCHASE ORDER# R05TE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> r <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTIONW QTY UNIT PRICE QTY PIU TOTAL <br /> I <br /> 1___dTOTAL ` <br /> _ASH REC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIUMIXED OILS)'NO PLACARDS REt-.'1UALD' 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 PN: EMPTY DRUMS: FACILITY: BSG <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certify that the waste described above is prop-0y classified,described,packaged,marked and labek•d and ism Prnpe7 Onditi 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 cid 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 /> p 02)1 have not mixed any of the waste described above with any other nazardous 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 /> p#J)This waste is from a tank which collects waste oil from household-do-it-yourself"(DIY)andlor conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste ci a contained in my DIY!CESQG collection tank is coley 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 /> Il 04) 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 /> -ticable 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 /> environment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waAe generation and select the best waste management method that is available <br /> to me that 1 can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />