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FOR SERVICE CALL: SERVICE ORDER • <br /> DIXON OFFICE FORM NO.AES004-B(REV 10107) <br /> 1-800-7-ASBURY I SER -E�012D�.f{NO. <br /> UNION CITY OFFICE <br /> 1-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> st11 ( 1,1i I ,, 1300 SOUTH SANTA FET COMPTON,CA90221 i;(r,l�l/r/fsliEal: ':krli:: <br /> H 1-310-886-3400 <br /> I ±�;- 11 <br /> P 1, TRANSPORTER EPA#CAD028277036 <br /> P <br /> E <br /> D <br /> Q <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> tt <br /> J s <br /> _.±!LRT* DESCRIPTION, , ,,.. .,. „ ., ,,,. Q. UNIT PRICE QTY PIU TOTAL <br /> . . _ . . <br /> L <br /> TOTAL <br /> CASHREC'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,LIQ%D ET�YLENE GL,YCQ4 SpQLYTIOVJ l.NO IFACA S RE� f ' $TATE CODE <br /> OTHER: )/N. )l ni(It J�ti:VRt)tI tA`i. />:.xiJttx 'R sl,,. i,rr 4.,�-b4'tt9.J, b9M1 cL <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF. <br /> 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 1 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.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.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#1)This waste is from a tank which collects waste oil from household"do-Il-younalr'(DIY)and/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 QIY and/or 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 me information I have provided about this waste is incorrect <br /> Y (All generators/customers MUST read the following text and check the associated box.) <br /> [ If I am a large quantity generator,1 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 me practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human life and <br /> b.- .avirorment;Or,it 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 />