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FOR SERVICE CALL: ` SERVICE ORDER <br /> FORM N0.AES004-B(REV 10/0 <br /> DIXON OFFICE <br /> 1-800-7-ASSURY I SERVICE ORER NO. <br /> UNION CITY OFFICE <br /> 1 -9-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> H ,I;tt-4 Y 1, tip 4,24`)";1. - � 1-310-886-3400 ,'.•;I: ,t ,I'�i3: i:,�(;' <br /> 1 <br /> P 4:4715 N. ' W[ fs�T LICE TRANSPORTER EPA#CA0028277036 <br /> E <br /> D <br /> T <br /> ij Ti e,a .f;.6`Y.. <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED -NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# - DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> .3.., tj:T 4-. III1,17 ilr-I a I I 41" -n <br /> I,,ICi Fl. i.£i L1:Ff_ ;` i'k;I;✓t.iif #57t..'> � �_: ,�;. <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: i1 P!Wtta ,� f F'4Ii(it� Urn'. DLXU90. Y'1 156J� d711 r i� fi41 tPoT'4F117 <br /> t hbi <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 I also hereby certify thil: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> #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.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,l <br /> have provided proper documentation to Asbury Environmental Services to rebut the presumption Mat 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 /> 0#3)This waste is from a tank which collects waste oil from household"do-it-youneir(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIV CESQG collection tank Is soloy 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 charges for disposal of this waste Blhe Information 1 have provided about this waste is Incorrect <br /> 1 (All generators/customers MUST read the following text and check the associated box.) <br /> p•"I If I am a large quantity generator,l certify that 1 have a program In place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically <br /> j able and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize.the present and future threat to human life and <br /> I. .vironment;Or,if I am a small quantity generator,I have made a goad 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 />