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FOR SERVICE CALL- SERVICE ORDER <br /> DIXON OFFICE • FORM NO AESGOiB(BEV IO/07) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 3-603-8644 RM <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE,COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> E 7' 1-111 4 1, 1. 1 1: <br /> O <br /> T <br /> 0 1 Ij 11.!! 1, <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRLCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> T <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> I It" 1�3 J' t l'" IJaE t f <br /> ij 0!;`+ I > <br /> 1`jIQ " <br /> .-,-l <br /> PART# DESCRIPTION CITY UNIT PRICE QTY PIU TOTAL <br /> J <br /> TOTAL <br /> ASH REC'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 /> CFR: 33210 Westqrn Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PIU: 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 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 /> D #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 arm,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 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 it the information I have provided about this waste is incorrect <br /> 0 93)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 DIV/CESQG collection tank is sifley from DIY anther CESQG sources.I have not mixed this 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 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 /> EI If I am a large quantity grea'atim,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> 'able 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 /> vrrcmacnt;Cu,if I a.a small q.antnariffirre.tor,I have made a good faith effort to minimize my waste generation and select the beat waste management method that is available <br /> me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />