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FOR SERVICE CALL: <br />DIXON OFFICE <br />1-800 / ASBUHY <br />1-1?1--.SNO <br />!69-49B 0140 <br />(,'/ /100 01-FIGf- <br />800-133-9043 <br />" ), , I �'� � � 11 ) <br />R`- - <br />SERVICE OROS <br />t ORM NO AU,001 B (RI -1/ VYW) <br />- SEP 15 2015 SERVICE ORDER NO, <br />-4 <br />V4 .. ..... <br />IME"NVIRONNIEN- At::, <br />ASBURY ENVIRONMENTAL SERVICES <br />1300 SOUTH I I SANTA FF, COMPTON, CA 90221 <br />1-310-886.3400 <br />TRANSPORTER E13A # GAD020277036 <br />7f <br />CUSTOMER # <br />PURCHASE ORDER # <br />ROUTE# <br />TRUCK# <br />CONTACT NAME <br />ORDER TAKEN BY <br />HALIDES <br />DATE REQUIRED <br />DATE ENTERED <br />NEXT SERVICE DATE <br />CUSTOMER EPA # <br />MANIFEST <br />JTK <br />PART# <br />DESCRIPTION QTY <br />UNIT PRICE QTY PCU TOTAL <br />TOTAL <br />CASH RECD: CHECK # I 1AY iI 10MI <br />H-11.1 <br />WASTE DISPOSAL INFORMATION <br />— NON-RCRA HAZARDOUS WASTE, LIQUID (USED CIUMIXED OILS) 'NO PLACARDS REQUIRED- <br />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 />SA 111 33210 Western Avenue, Union City, CA 94587 1-510-487-9277 <br />DRUMS PIU:_ EMPIYDRUMS: FACILITY: BSC <br />GENERATOR WASTE CERTIFICATION <br />PLEASE CHECK THE APPROPRIATE BOX <br />This I. to certify that tire waste described above Is lKolurdy classified, described, packaged, marked and labeled. avid Is (it pfoper condition for tran"llAtion, accolding to applivable, State <br />and federal regulations. fly shining below I also hereby certify that: <br />(Waste oil generator/customer MUST check ONE of the following three boxes) <br />ill i I have not nliml any of the waste described above with any other hazardous waste, Ilia total halide content is LESS than 1,000 ppm, and the waste does not contain any PCOs. I have <br />c.�uplhid with the ocilubelliouls of live 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 />it the uhilminalioil I have provided about this wavdiv, is incorrect <br />C) B2)1 have not mixed any of tire waste described above with any other itiviarthius waste, the total While confetti is GREAUR IhAn 1.000 ppm, and the waste does not cool.tin any PCNs. I <br />have provided proper documentation to Asbury FOV11011"1011011 S6fViC0fi 40 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 it Its information I have provided about this waste In Incorrect <br />IL 01) this waste it, horn a l4ok which collects waste oil from household"do-it-yourself' (01y) and/or conditionally exempt small quantity generator (CESQG) sources. To itin best of my <br />i , <br />kol%lodbo, the only waste oil ronlained Ill any DIY/ CESQG collection lank is soley from DIY and/or CESQG sources. I have not mixed this waste oil with any other hazardous waste or <br />waste oil from other sources.��1.11 on to accept the additional charges for disposal of this waste If tire Information I have provided about this waste Is Incorrect <br />(AI erators/customers MUST read the following text and check the associated box.) <br />X#4) It I am a large quantity gene I rtify that I have a program In place to reduce Ilia volume and toxicity of waste generated to tire degree I have dolorillivi I to be economically <br />t!cticablo all,] that I have select I .. his method of treatment, storage, or disposal coneotly available to tire which rultilinlyes the present and future IhrjZ to human life and <br />Ilia onybonniont; or, if I va s I Is y 11 alar, I have made a good faith effort to minimi®® my waste generation and select the best waste qrsa that is available <br />to rov, that I ran affollil// <br />Lmer Sigiiature ate river Signature Date <br />riot Name Print Drivers Name <br />