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rFORVICECALL: - �, SERVICE ORDER FORdNO.ACS004B(REV10/07) <br /> FFICE <br /> SBURYSERVIG,EORDER NOITY OFFICE-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H ! 1-310-886-3400 t3i;A itnit l'I 'iF <br /> TRANSPORTER EPA#CAD028277036 <br /> p <br /> E <br /> D <br /> - <br /> T <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATEREQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> " TjC •t ;Irv; tl�_v,Y. , ...�-. _ �.. ._ <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> ,.., .i: EI, ' i• 71 £ <br /> TOTAL <br /> CASH RECD: 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: It r utxii,i., rol'.t i!^E"Ms:#a o3k't„ ,)salt t2, " ';. •:"{ ht}r+a,� rtit�;ktFr;,r�;;i?. <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 properly 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 /> (F,#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 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 infonnati an I have pmvi dad 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.1 <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption that this waste was mixed with other hazardous waste.)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 /> .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 DIYI CESQG collection tank is soley 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 /> Ir edl 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 /> 'cable 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 /> ovirenmentl 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 l can afford <br /> Customer Signature"" Date DriverSignature Date <br />