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• SERVICE ORDER • <br /> SAN DIEGO OFFICE FORM NO.AEsooa-B <br /> 1-800-748-5744 SERVICE ORDER NO. <br /> NORTHERN OFFICE <br /> `10-7-ASBURY <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s <br /> 1300 SOUTH SANTA FE, COMPTON CA 90221 <br /> � ��, � -t.1L. tk k.4� LOS OFFICE SAN DIEGO OFFICE NORTHERN OFFIC€E fl�n� 5^ <br /> P .7 1-800-974-4495 1-800-748-5744 1-800-7-ASBURY E.'( i/_'f%Ac'E INC, <br /> EP 4;'t � P4. wrST LAW. 1471 ;�i ORL ST' <br /> D TRANSPORTER EPA#CAD028277036 ' <br /> T iTOCKTON, CA 994210 (VEST ti CRIAMENTtt, C' '., ; <br /> 0 <br /> CUSTOMER# PURCHASEORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKENBY HALIDES <br /> •) I1 A7;-., 9_i 1L:3.`9[:: 1 b ii t,t<: <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> / Ito/100& 9/7,, 2,30 ` ,, , 5 ; <br /> PART# DESCRIPTION QTY. UNIT PRICE QTY PIU TOTAL <br /> OF 0 >I- t3 OIL ANO (:A440L. F NI' F 1 LT'r,R <br /> TOTAL <br /> ,;ASHREC'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 /> ALTERNATETSDF: <br /> y CFR: 33210 Western 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 /> ❑ #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.l 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)]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 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"tlo.f yourself'(DIV)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,/he only waste oil contained in my DIYI CESQG collection tank is Soley from DIY andfor 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 chargee for disposal of this waste ifthe information I have provided about this waste Is Incorrect eI <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> 0#dl If 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 /> table 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 /> ;vimumenp Or,if 1 am a small quantity generator,these made a good faith effort to minimize my waste generation and select the best waste management method that is available <br /> m me that i can afford. .» ' <br /> Customer SignatureDate Driver Signature:' r Date l <br /> Print Name Print Drivers Name <br />