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FOR SERVICE CALL: . SERVICE ORDER <br /> DIXON OFFICE FORM NO.AES004-B(REV 10107) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> '8-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> x 1-310-886-3400 <br /> I <br /> P .t�) } r ) ;.jlN( r, "'-. _ TRANSPORTER EPA#CAD028277038 ' I•`= F a ""- `}tt: <br /> E _. <br /> D <br /> 7 <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# [ 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 /> r °i'i • �, '�i i <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: t . <br /> DESIGNATED TSDF: t ..t .. ,=i ..:z, .. <br /> ALTERNATE TSDF: <br /> CFR: 33210 Western Avenue, Union City,CA 94587(510)487-9277 <br /> DRUMSPN: 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 that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> D #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 /> ❑#2)1 have not mixed any of Ne 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 I have providetl about this waste is incorrect <br /> p#3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)andlor conditionally exempt small quantity generator(CESQG)sources.To the best of my <br /> knowledge,the only waste oil contained In my DIM CESOG collection tank Is coley from DIY and/or CESQG sources.I have not mixed this waste oil with any other hazardous waste or <br /> waste it from other sources.I agree to accept the additional charges for disposal W 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 /> 1-`4) III 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 /> icable 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 /> >nvironmenp Or,If I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the belt waste management method that is available <br /> to me that I can afford <br /> Customer Signature Date Driver Signature Date <br />