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I SERVICE ORDER <br /> SAN DIEGO OFFICE • • FORM NO.AES004-6 <br /> 1-800-748-5744 _ SERVICE ORDER NO. <br /> NORTHERN OFFICE <br /> `9-7-ASBURY <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> H <br /> LOS ANGELES OFFICE SAN DIEGO OFFICE NORTHERN OFFICE.''- <br /> 1-800-974-4495 1-800-748-5744 1-800-7-ASBURY I <br /> D aTRANSPORTER EPA#CAD028277036 <br /> T If- <br /> G <br /> CUSTOIMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> . f, 1 '11 ftl[ -7-, 77 7 <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART 5'ESCRIPTION QTY UNIT PRICE QTY PILI TOTAL <br /> ' <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 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 descri bad above is pr.md,classified,des.rilhad,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 #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 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 /> 0#2)1 have not mixed any of the waste described above with an,other hazardous..afa,the total halide content is GREATER than 1,000 rpm,and the waste does not contain any PC8a.I <br /> have provided proper documentation to Asbury Environmental Services to oflout 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 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-yourself'(DIY)andl,ar conditionally exempt small quantity generator(CESOG)sources.To the beat of my <br /> knowledge,the only waste oil contained in my MY/CESQG collection tank is solay from DIY 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 /> 0 41 It I am a large quantity generator,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 /> ,vfircman.dtl Or,if I am a small quantity generaton,I have made a good faith effort to minimize my waste gear ration and select the best waste management me bad that is available <br /> to an.that I can afford. <br /> Customer Signature Date Driver Signature <br /> bate <br /> Print Name Print Drivers Name <br />