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FOR SERVICE CALL: • SERVICE ORDER • <br /> DIXON OFFICE FORM NO AES004-B(REV 10107) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240 a <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> Sy 1300 SOUTH SANTA FE, COMPTON, CA 90221 _ <br /> " i'.liJ..':'' I'd 'cti1 A 1(11RE 111 1-310-886-3400 <br /> P ;'.24 "; i3�,ild_:d+�. 4'.f 4•'JrTRANSPORTER EPA#CAD028277036 t15317 I. F)IAIiK> I"3T <br /> E <br /> D <br /> T �r, .. <br /> O .I 1 :ail$X , ;'I asZ-304 <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> Ci1 <br /> PART# DESCRIPTION QTY I UNIT PRICE QTY PIU TOTAL <br /> 1 <br /> i45lYibtx. i4T%;! �T•;q,T t^tf# �}r rR!$hSL TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROMI HIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION 11 <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 i, , y-:,r„ • r - t• niliiPy:TO"ai,. .� <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 33210 Western Avenue, Union City,CA 94587 1-510-487-9277 <br /> DRUMS PN: - 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 con lillon 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 /> /106)1 have not mixed any of the waste described above with any other hazardous waste,the total halide content is LESS than 1,00 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.1 agree to acct pt the additional charges for the disposal of this waste <br /> ff the information I have provided about this waste is incorrect <br /> D#211 have not mixed any of the waste described above with any other hazardous waste,the total halide content is GREATER than 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 /> D#0)This waste is from a tank which collects waste oil from household"do-ftyoursalr•(DIY)andfor conditionally exempt small quantity generator JCESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESGG collection tank is solely from DIY andlor CESQG sources.I have not mixed jhis 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 me information I have provided about phis waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> �aa) If I am a large quantity generator,I certify that 1 have a program In place to reduce the volume and toxicity of waste generated to he degree I have determined to be economically <br /> facticable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize the present and future threat to human life and <br /> J the environment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the pest waste management method that is available <br /> to me that l can afford - �I <br /> " -, <br /> , ,... <br /> �.y� ,Y 1 R <br /> Customer Signature Date l Driverstn tur Dat ? <br /> 4 w <br /> Print Name Print Urive s Name <br />