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q <br /> FOR SERVICE CALL: ,• SERVICE ORDER . <br /> DIXON OFFICE FORM N0.AE5009-B(REV 10N7) <br /> 1-800-7-ASBURY _ SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> '8-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 <br /> E <br /> D <br /> o <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> r' :a <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY _ UNIT PRICE QTY P/U TOTAL <br /> 17— <br /> TOTAL <br /> CASH RECD: 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 /> DRUMSPIU: -'--''� 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 /> ❑ #1)I 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 PCBa.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.1 agree to accept the additional charges <br /> for Me disposal of this waste if the information I have provided about this waste is incorrect <br /> D#3)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 DIY/CESOG collection tank Is coley from DlY 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 1 have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 0«al 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 the degree I have determined to be economically <br /> :able and that I have selected lie practicable method of treatment,storage,or disposal currently available to me which minimizes thepresent and future threat to human life and <br /> ,vimnment; Cr,if 1 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 /> CustomerSignature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />