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• DIXON OFFICE SERVICE ORDER <br />1-800-7-ASBURY <br />UNION CITY OFFICE <br />1-888-603-8844 labor <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH SANTA FE, COMPTON CA 90221 <br />1-800-974-4495 <br />TRANSPORTER EPA # CAD028277036 <br />FORM N0. AES004 B (REV 10107) <br />SERVICE ORDER NO. <br />CUSTOMER # <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES <br />I <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE <br />DATE <br />CUSTOMER EPA # <br />MANIFEST# <br />PART# <br />DESCRIPTION <br />QTY <br />UNIT PRICE <br />QTY PN <br />TOTAL <br />TOTAL <br />CASH RECD: CHECK # <br />WASTE DISPOSAL INFORMATION <br />NON•RCRA HAZARDOUS WASTE, LIQUID (USED OILIMIXED 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 />CFR: 33210 Western Avenue, Union City, CA 94587 (510) 487-9277 <br />DRUMS P/U: 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 property Gassified, 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 tate 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 man 1,0110 ppm, and the waste does not contain any PCBs. I have <br />complied with Me requirements of We applicable California used oil management regulations to determine this Is true. I agree to accept Me additional charges for the disposal of this waste <br />if the information I have provided about this waste is Incorrect <br />O #2)? have not mixed any of Me waste described above with any other hazardous waste, the total halide content is GREATER man 1,000 ppm, and the waste does not contain any PCBs. I <br />have provided proper documentation to Asbury Fnviromnental Services to rebut Me presumption that this waste was mixed with other hazardous waste. I agree to accept Me addtional charges <br />for But disposal of Mia ..at. If the Informed. I have provided about this waste is incorrect <br />D 43) This waste is hem a tank which collects waste oil from household "dotit.yourself' (DIY) andtor conditionally exempt small quantity generator (CESQG) sources. To the best of my <br />knowledge, the only waste oil contained in my DIYI CESQG collection tank Is soley from DIY andlor CESQG sources. I have not mixed this waste oil with any other hatardous waste or <br />waste oil horn other sources. I agree to accept Me additional charges for disposal of MIS to if Me information I he. provided .bout Ws waste Is incorrect <br />(All generators/customers MUST read the following text and check the associated box.) <br />0 ") If i am a large quantity generator, l certify that I have a program in place to reduce that volume and toxicity of waste generated to the degree I have determined to be economically <br />pract cable artd that i have Selected Me practicable method of h iahnent, storage, or disposal currently available to me which minimizes Me present aM future threat to human life and <br />Me environmerd:Or, if I am a small quantity generaloq 1 have made a good faith effort to minimize my waste generation and Select Me beat waste management method that is available <br />to me Mat I can afford. <br />—1 1 — <br />Customer <br />Customer Signature Date Driver Signature Date <br />Print Name <br />Print Drivers Name <br />