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DIXON OFFICE <br />1-800-7-ASBURY <br />UNION CITY OFFICE <br />1-888-603-8844 <br />SERVICE ORDER • <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH SANTA FE, COMPTON CA 90221 <br />1-800-974-4495 <br />TRANSPORTER EPA # CAD028277036 <br />FORM NO. AES004-B (REV 10/07) <br />SERVICE ORDER NO. <br />CUSTOMER # <br />PURCHASE ORDER # <br />ROUTE # <br />TRUCK # <br />CONTACT NAME <br />ORDE7_1R TAKEN BY <br />HALIDES <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER EPA # <br />MANIFEST# <br />PART # <br />DESCRIPTION QTY <br />UNIT PRICE QTY PIU TOTAL <br />TOTAL <br />CASH RECD: CHECK# PLEASE PAY FROM <br />THIS SERVICE ORDER <br />WASTE DISPOSAL INFORMATION <br />- <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 />DESIGNATEDTSDF: <br />ALTERNATE TSDF: <br />CFR: 33210 Western Avenue, Union City, CA 94587 (510) 487-9277 <br />DRUMS PN: EMPTY DRUMS: FACILITY: BSC <br />GENER OR 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 />0 #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 />D #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 PCes. 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 Me additional charges <br />for Me disposal of this waste if the information 1 have provided about this waste is incorrect <br />D 113) 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 Dim CESQG collection tank is splay 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. l agree to accept Me additional charges for disposal of this waste if Me 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 #a) 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 1 have determined to be economically <br />practicable 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 />the environment; Or, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste generation and select the best waste management method thefts available <br />to me that I can afford. <br />Customer Signature Date Driver Signature Date <br />Print Name <br />Print Drivers Name <br />