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FOR SERVICE CALL: SERVICE ORDER . <br /> DIXON OFFICE FORM N0.AES0048(REV 10107) <br /> 1-800-7-ASBURY SERVICE ORDER NO. <br /> UNION CITY OFFICE <br /> 1 -13-603-8844 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE, COMPTON, CA 90221 <br /> H ) ), 1-310-886-3400 <br /> P <br /> ,tr,. I.at L„(,Ip;} ;�,-•r,',' ;- TRANSPORTER EPA#CAD028277036 <br /> D <br /> T 1e11713f.'T(:Aii" 4„/) 0 _ tt!� J C)" i a+ '. <br /> CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDES <br /> DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> 4W,, <br /> I . <br /> PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL <br /> irtt"#',i' i',Lt) ff.3'G #';liLd:if is (:,EIARGi-,, !- <br /> 1i <br /> 0'.J l 01 h YX i) ti:li.,"u N; <br /> TOTAL <br /> CASH REC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> NON-RCRA HAZARDOUS WASTE, LIQUID(USED OIL/MIXED 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: € t_ H`(4!1, 1'3w, Cffl Yol1M 8fii, Pi ,A, Cr1 Y_c.1t <br /> ALTERNATE TSDF:. <br /> CFR: 33210 Western Avenue, Union City, CA 94587(510)487-9277 , <br /> DRUMSPAU: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This is to certity that the waste described above is property classified,described,packaged,marked and labeled,and is in proper condition for transportation,according to applicable Stale <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 PCB9.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 the disposal of this waste if the information I have provided about this waste is Incorrect <br /> 0 43)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIY)and/or conditionally exempt small quantity generator(CESQG)sources.To the lest of my <br /> knowledge,the only waste oil contained in my DIY/CESQG collection tank is Soley from DIV antllor 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 Ne Information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> Q#dl If I 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 1 have determined to be economically <br /> gable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimize.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 />