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SAN DIEGO OFFICE SERVICE ORDER• � FORM NO.AES004-B <br />1-800-748-3744 SERVICE ORDER NO. <br />NORTHERN OFFICE <br />1-800-7-ASBURY — — <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH SANTA FE, COMPTON CA 90221 <br />LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICE <br />1-800-974.1495 1-800-748-5744 1-800-7-ASBURY <br />TRANSPORTER EPA # CAD028277036 <br />CUSTOMER # <br />PURCHASE ORDER # <br />ROUTE # TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES <br />CUSTOMER EPA# <br />-- MANIFEST# <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />i <br />PART # DESCRIPTION A �-� <br />UNIT PRICE <br />QTY P/U <br />TOTAL <br />___QTY <br />I <br />TOTAL <br />CASHREC'D: CHECK# PLEASE PAY FROM THIS Ste...._ <br />WASTE DISPOSAL_ INFORMATION <br />NON-RCRA HAZARDOUS WASTE, LIQUID (USED OILIMIXED OILS) aNO PLACARDS REQUIRED- STATE CODE 221 <br />NON-RCRA HAZARDOUS WASTE, LIQUID (ETHYLENE GLYCOL SOLUTIONS) *NO PLACARDS REQUIRED- STATE CODE _ <br />OTHER: _ _ <br />DESIGNATED TSD.__� <br />ALTERNATE TSDF: <br />_ <br />GFR: 33210 Western Avenue, Union City, CA 84587 (510) 487-9277 <br />DRUMS PIU: EMPTY DRUMS: FACILITY: BSC <br />GENERATOR WASTE CERTIFICATION <br />PLEASE CHECK THE APPROPRIATE BOX <br />This 15 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 1 also hereby certify that: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />D #1)1 have riot 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. l have <br />complied with the requirements of the applicable California used if management regulations to determine this is true. I .,,as to adept Hu. additional charges for the disposal of this waste <br />if Me information I have provided about this wast. is incorrect <br />D #2)1 have not mixed sty of the waste described ab.v- with any other hazardous was is, the total halide content is GREATER than 1,D00 ppm, and the wast, does net contain any PCs.. I <br />have provided proper documentation to Asbury Environmental Services t. but the presumption that this waste was mixed with other hazardous waste. I agree to accept the additional charges <br />for Me disposal of this ...to if the information 1 have provided about this waste is incorrect <br />D 03) This waste is from a lank which cula<le waste it from he ... hold "do-ibyourselr(DIY) and/or conditionally exempt -mall quantity generator (CESOGI sources. To the best of my <br />knowledge, the only waste oil contained in my DIY/ CESOG collection tank is soley from DIY and/or CESQG sources. I have not mixed this waste oil with any other hazardous waste m <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 genes ame I certify that I have a program in place to reduce the volume and toxicity of waste generated to Me degree I have determined to be economically <br />practicable and that I have selected Me practicable method of treatment, storage, or disposal currently available to ren which minimizes the present and future threat to human life and <br />the environment; Oq if I am a small quantity generator, l have made a good faith effort to minimize my waste generation and sated the best waste management method that is available <br />to on, Mat I can afford. <br />Customer Signature Date Driver Signature Date <br />Print Name <br />Print Drivers Name <br />