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FOR SERVICE CALL: SERVICE ORDER • FORM NO.AES004-B(REV 10/07) <br /> DIXON OFFICE <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 588-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> R i 1-310-886-3400 . <br /> TRANSPORTER EPA#CAD028277036 <br /> P .. 5 <br /> P 1`} 111 <br /> E <br /> D <br /> T <br /> CUSTOMER# PURCHASE ORDER# ROUTE# j TRUCK# CONTACT NAME ORDER TAKEN BY I HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> I .a� ,.[ ', i <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> , 100 I I,'P, t i .{.{f',,.i.tp. _ <br /> ,�O L?t it !-4.'t a, f? x .' 11.` a} J.I.�.. ✓ r ,,... ,� ti <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,LIQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED` STATE CODE— <br /> OTHER: <br /> ODE_OTHER: <br /> DESIGNATED TSDF: <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> ,DRUMS PIU: EMPTYDRUMS: 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 l also hereby certify that: <br /> (Waste oil generator/customer MUST check ONE of the following three Loxes) <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 /> G#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 wan mised 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 /> #3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)andlor conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is Soley from DIV 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 the additional charges for disposal of this waste if Me information I have provided about this waste is incorrect <br /> J (All generators/customers MUST read the following text and check the associated Lox.) <br /> `t1#a) 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 I have determined to be economically <br /> lcticable and that 1 have selected Me practicable method of treatment,storage,or disposal currently available to me which nnnimizes the present and future threat to human life and <br /> .environment;Or,111 am asmall quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management m§lhod that is available <br /> to me that I can afford, <br /> Customer Signature Date Driver:Signature Date <br /> i <br />