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FOR SERVICE CALL: 40 SERVICE ORDER ` <br /> DIXON OFFICE FORM NO.AE5004—e(REV 10/07) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1 '1-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> R 1-310-886-3400 <br /> 1 iI ' ' IV' : I TRANSPORTER EPA#CAD028277036 <br /> P <br /> P 'I, <br /> E <br /> D <br /> O <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 P/U TOTAL <br /> TOTAL <br /> CASH REC'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 /> DESIGNATED TSDF: `•I'`Ut..^ `° t — '.., M Eft, I) :;v, i'N 'tC 1+. Irr r ., �sgt+I r-�•+: <br /> ALTERNATE TSDF. <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 <br /> DRUMS PN: 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 /> b.#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 tha 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 1 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.I agree to accept the additional charges <br /> for the disposal of this waste if the information 1 have provided about this waste is incorrect <br /> 0#3)This waste is from a tank which collects waste it from household"do-it-yourself'IDIY)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 splay from DIY surfer 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 /> u0e1 If I am a large quantity generator,I cerlify 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 /> 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 /> L .vironment;Or,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the bast waste management method that is available <br /> to me that I can afford. <br /> Customer Signature + Date Driver Signature Date <br />