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FOR SERVICE CALL: SERVICE ORDER • <br /> DIXON OFFICE FORM N0.AES0046(REV 10107) <br /> 1-800-7-ASBURY 1 SERVICE ORDER NO. + <br /> UNION CITY OFFICE <br /> 1 `R-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON, CA 90221 •- <br /> H 1-310-886-3400 <br /> a - TRANSPORTER EPA#CAD028277036 ✓ ::I ; i II. <br /> P <br /> E F; ' . + '3 . . ,{ T.. <br /> T <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDERTAKENWT7 HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> TOTAL <br /> CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION `• <br /> NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIL/MIXED 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 certity 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 /> #i)1 have not mixed any of the waste described above with any other hazartlous 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 /> ❑#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 tha 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 it from household"do-i[-yourself'(DIY)antl/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIYI CESQG collection tank is coley from DIV andlor 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 /> ❑#a) If I am a large quantity generator,I certity that I have a program in placeto reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> r able and that I have selected the er.ofci bl.method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> I, iironment;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 available <br /> to me that I can afford. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />