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I <br /> FOR SERVICE CALL: • SERVICE ORDER • <br /> DIXON OFFICE <br /> FORM NO.AESD04-B(REV 10/07) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1'- 4603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> H 1HFY l iJ,!kl: f,249 1-310-886-3400 }fya)I d/6F1fiE Jlf#_ <br /> P <br /> .- ,(y� i,1e. U ,l,,) f, I (.. TRANSPORTER EPA#CAD028277036 <br /> P <br /> E <br /> D <br /> T <br /> CUSTOMER# PURCHASEORDER# ROUTE# j TRUCK# CONTACT NAME ORDERTAKENBY 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: 1 041 ce it"t : t311 (-I 'ts '''�" a 'S i1r4r 1112nitf,�,x; <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF. <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PN: EMPTY DRUMS: I 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.l 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)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!CESQG collection tank is Soley from DIY and/or CESQG sources.l have not mixed this waste oil with any other hazardous waste or <br /> waste oil from other sources.1 agree to accept the additional charges for disposal of this waste if me information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> LY'41 If 1 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 1 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 /> 1. nironment;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 1 can afford. ` <br /> Customer Signature Date Driver Signature Date <br />