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FOR SERVICEdALL: ' • SERVICE ORDER FORM NO.AESWIB(REV 1=7) <br />DIXON OFFICE <br />1-800-7-ASBURY _ SERVICE ORDER NO. <br />FRESNO <br />-- <br />5#498-0240 _= — _ _ — � �'�"`-`� J4li0OFFICE <br />33-9043 <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH SANTA FE, COMPTON, CA 90221 <br />R - i d; 1-310-886-3400 rlil�r _'rP �.il niri.�t i -+•�• i im v; :; .n « <br />,��1 kb EPA #CAD028277036 t'.`. F._ )(" �,.'-.ttF� J�rY. ..,., <br />CUSTOMER# <br />PURCHASE ORDER# <br />ROUTE* <br />TRUCK# <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE <br />DATE <br />CUSTOMER EPA# <br />MANIFEST# <br />PART # DESCRIPTION <br />QTY <br />UNIT PRICE QTY PIU T,OTgL- <br />-iLy <br />-1 1'i�f{�/�•jri f� •:.'I (I.il i•f'vf y`�/ <br />'y <br />ti <br />. /?YI't i ��{ ...✓ -Y/V 4h y i'x[^!Q { 3��({yi <br />i/" <br />( <br />rr. <br />TOTAL <br />CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <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 />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 candy that the waste described above is property classified, described, packaged, marked and labeled, and is in proper condition for transportation, according to applicable Stale <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 Oki l have not mixed any of the waste described above with any other hazardous waste, the total halide content is LESS then 1,000 ppm, and the waste does not contain any PCBs.I have <br />complied with the in,immants of the applicable California used oil management regulations to determine this Is true. i agree to accept the additional charges for the disposal ut this ...Is <br />if the Information l have provided about this waste is incorrect <br />0 x3)1 have net mixed any of the ...in described above An any ether nazardous was as. the total halide content is GREATER than 1.W0 ppm, and the waste does not contain any PCS.. 1 <br />have provided proper documentation to Asbury Environmental Services to rebut the presumption Mal this waste was mixed with other hazardous waste.I agree to accept Me additional charges <br />for the disposal of Mia waste if Me information I have provided about this waste is incorrect <br />p e3) This waste is from a tank which collects waste ON from household "do-it-youreelr (DIY) and/ar conditionally exempt small quantity generator (CESOG) sources. To the beat of my <br />knowledge, Me only waste oil contained In my DIY? CESGG collection tank Is Soley from MY andlor CESOG sources. I have not mixed Min waste oil with any other hazardous waste or <br />waste oil from other sources. I agree to accept the additional charges for disposal of Mia 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 />OIf 1 am a large quantity generator, I Certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />ble and that 1 have selected the practicable method of froabnant, stwege, or disposal mrtently available to me which minimizes the present and future threat to human life and <br />rnament; Or, If I am a small quantity generator, I have made a good faith Won to minimize my waste generation and select the best waste management method that is available <br />to me that I can afford. <br />Customer Signature Date <br />Driver Signature Date <br />Print Name Print Drivers Name <br />