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FOR SERVICE CALL: SERVICE ORDER <br /> DIXON OFFICE FORM N0.AES000.B(REV 10/07) <br /> 1-800-7-ASSURY I SERVICE ORDER NO. <br /> UNION CITY OFFICE - <br /> 1 ­13-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s i_(1,1 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H 1-310-886-3400 <br /> TRANSPORTER EPA#CAD028277036 - <br /> P <br /> E <br /> ° <br /> 0 <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. UNITPRICE QTYPIU TOTAL <br /> !'i1 it'd! f = .ill': +T -Y - <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, LIQUID SETHYLENE GLYCOL SOLUTIONS)-NO PLACARDS REQUIRED` STATE CODE <br /> OTHER: i; ' [ iN{,4, k.r� r,l'.'e11 ! nift'i. I ! t' . Ct: .F. :.1,£�S?k�, t,wloitrfis' .,7. <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS RU: 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 /> #i)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 ail 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 /> °#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 me presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charges <br /> forme disposal of this waste if the information I have provided about this waste is incorrect <br /> 0#J)This waste is from a tank which collects waste oil from household"dowit.younself'(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the beat of my <br /> knowledge,the only waste oil contained In my DIYI CESOG collection tank is soley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste oil from other sources.I agree to accept me 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 /> '0#41 If 1 am a large quantity generator,I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> r iable 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 /> vironment;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 I can afford. <br /> Customer Signature Date Driver Signature Date <br />