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FOR SERVICE CALL: • SERVICE ORDER <br /> DIXON OFFICE FORM NO.AESOOAB(REV 10N7) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE _ <br /> 1 --9-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> H1-310-886-3400 <br /> 1 ' I , ; t :1 TRANSPORTER EPA#CAD028277036 <br /> P <br /> P <br /> E <br /> D <br /> T <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 UNIT PRICE QTY PIU TOTAL <br /> r� <br /> TOTAL <br /> CASH RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS.WASTE,LIQUID(USED OIUMIXED 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: ... <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 propedy classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable Slate <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 /> #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 /> 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 Ne disposal of th is waste if the information I have provided about this waste Is Incorrect <br /> F#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 beat of my <br /> knowledge,the only waste oil contained in my DIV CESOG 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.1 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 /> 'C '�l If I am a large quantity generator,1 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 /> :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 /> �. .vironorent;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 1 can afford. <br /> Customer Signature I Date Driver Signature Date <br />