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FOR SERVICE CALL: SERVICE ORDER FORM NO AES004-B(REV 10/07) DIXON OFF/CE 1-800-7-ASBURY SERVICE ORDER NO. 77 1 UNION CITY OFFICE 3 0" ' 1-888-603-8844 Zile IMF _ _,> CHICO OFFICE 800-733-9043 ASBURY ENVIRONMENTAL SERVICES 1300 SOUTH SANTA FE,COMPTON, CA 90221 S 1-310-886-3400 I I.-.I I?I'd��j'`( 1-`IRI`. I':I �.I.I i�(,�� I.,"I:I'R&SPORTER EPA#CAD028277036 24124 N DRUI`'[A.A RD D ACAMP01, GA ,ter, , CUSTOMER# PURCHASE ORDER# ROUTE# TRUCK# CONTACT NAME ORDER TAKEN BY HALIDE .� ),°', 4 ; DATE REQUIRED DATE ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# ! 1/4/2o'll 010i:ill_.4t+;} �a"I,ta-''?t�r`:} �' f•,.,.._/((� PART# DESCRIPTION QTY UNIT PRICE QTY P/U TOTAL Fri 5f 4,7_ U Q. 0 I W 0 l!s Vi"11 WasC., USI.-L) 01L.. kaI I tI:CI � l::Nd:�I�CwI. TOTAL CASHREC'D: CHECK# PLEASE PAY FROM THIS SERVICE ORDER WASTE DISPOSAL INFORMATION NON-RCRA HAZARDOUS WASTE, LIQUID(USED OILIMIXED OILS)'NO PLACARDS REQUIRED' STATE CODE 221 NON-RCRA HAZARDOUS WASTE,UQUID(ETHYLENE GLYCOL SOLUTIONS)'NO PLACARDS REQUIRED' STATE CODE OTHER: OtK DESIGNATED TSDF: f ALTERNATE TSDF: SA RECYCLING: 33210 Western Avenue, Union City,CA 94587 1-510-487-9277 DRUMS PN: EMPTY DRUMS: FACILITY: BSC GENERATOR WASTE CERTIFICATION PLEASE CHECK THE APPROPRIATE BOX 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 and federal regulations.By signing below I also hereby certify that: (Waste oil generator/customer MUST check ONE of the following three boxes) ❑ #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 complied with the requirements of the applicable California used oil management regulations to determine this Is true.1 agree to accept the additional charges for the disposal of this waste if the information I have provided about this waste is incorrect ❑#2)]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 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 for the disposal of this waste if the information I have provided about this waste is incorrect p#3)This waste is from a tank which collects waste oil from household"do-it-yourself-(DIY)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my knowledge,the only waste oil contained in my DIY/CESOG collection tank is Soley from DIY and/or CESOG sources.I have not mixed this waste oil with any other hazardous waste or waste oil from other sources.I agree to accept the additional charges for disposal of this waste if the information I haws provldOW"out this waste is incorrect (All generators/customers MUST read the following text and Deck the associated box.) ❑#4) If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste general to th "llegres I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which mitizes t esent and future threat to human life and the environment;Of,if I am a small quantl y generator,I have made a good faith effort to minimize my waste generattorj and sa,ec,.the b taste management method that is available to me that I can afford. Customer Signature Date rive Sitore $ Date Print Name Print Drivers Name