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FOR SERVICE CALL: • SERVICE ORDER • <br /> DIXO)V OFFICE FORM NO.AES004-8(REV 10N7) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1 --q-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> 1 TRANSPORTER EPA#CAD028277036 F;(fi?f}t^ri�pt(.yi,,p' 3;i-iL <br /> E A 1-7" 1. 40RE. ";T <br /> D <br /> T '. ' WV" <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKENT77 HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILlMIXED 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 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 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 #i)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 /> compliedwith 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 /> 0#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.)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 /> 0#3)This waste is from a tank which collects waste oil from household"do-it-you mell"(DIY)andfor conditionally exempt small quantity generator(C ESOGI sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESOG collection tank is inlay from DIY andlor CESQG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste it 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 /> (Ail generators/customers MUST read the following text and check the associated box.) <br /> 0#al If I am a large quantity generator,I candy 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 /> I able and that 1 have selected Ne practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> t, di ronment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is evai l able <br /> to me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />