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• Page 2 September 18,2012 <br /> FARM NU.AtY.ii <br /> No. N 759423 <br /> BURY EWRONMENTAL SEMCES <br /> 1340 S.SANTA FE AVENUE C COMPTON,CALIFORNIA 90221 p (310)886-3400 <br /> EFA#CAD028277036 <br /> DIXON UNION CITY CHICO FRESNO <br /> 800-727-2879 888-603- 800-733-9043 -6937 <br /> DATE ONE TIME PICK UP (I VES or I]NO <br /> CUSTOMER <br /> RESIDENCE 0 YES or❑W <br /> BILLING ADDRESS CONTRACT CUSTOMER ❑YES or 0 W <br /> PLEASE FAQ'FROM THIS <br /> SERVICE GIRDER <br /> PHONE '"` - a'' CONTACT ^"" 7> z yam® CUSTOMER NUv <br /> CUSTOMER K ;`"C --— „I C a- T <br /> JOB SITE ADDRESS a CHECK NUMBER <br /> J'^%:^' „. -,>^ �'pY,,,A'"�``•>T P.O.NUMBER <br /> CROSS STREETS CASH RECEIVED <br /> NOTES: COMMODITY--./---/ ——I <br /> HAUDES<--' e ' P.P.M. <br /> 4:'y'NO9HAZARDOUS WASTE,LIQUID(USED OI LXED OILS)STATE CODE 221 <br /> -NO PLACARDS REOUIRED• <br /> ❑ NON-RCRA HAZARDOUS WASTE,LIQUID(ETHYLENE GLYCOLSOLUTIONS)SLATE CODE_"_. <br /> •No PLACARDS OR MARKINGS RE IRED* NEXT SERVICE DATE <br /> Z OTHER DRUMS SIS <br /> MANIFEST NO. ''.'` 7 „� ) NO.OFGALLONS <br /> DRIVER '-� :° IFIUCK NO.&PIT e, <br /> J USED OIL AND GASOLINE FILTERS <br /> ,1 SA RECYCLING, 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> C ALTERNATE FACILITY <br /> DESIGNATED TSDR 0 ASBURY ENtflRONMTITAL SERVICES*2549 SiMx Avenue+Chico,CA 95928•CAL000827844 <br /> C ASBURY Ep41ROMMENTAL SOWES-CHICO 04 LLC•1618 W.5th St.,Chico,CA 95928•CAD980694103•(800)733-9693 <br /> ❑ ASBURY ENVURONMENTAL ES-FO •200 Dinsmore Dr.,Fortuna,CA 95W•CAL930256136• 733-9043 <br /> INC. •1620 E. '- Ln.• ,CA 93307•GAL 62598•(661)377-0308 <br /> p OtK DIXON. .+ Way•Dixon,CA '+CAT 12602•(707)693-6008 <br /> • N.Ala St •Canpton,CA •CA 13352•(310)537-7100 <br /> +4139 N.Valentine Ave.•f GA 93722• •(510)795-4400 <br /> ra}- AL•15t5 S.Raver R .Sacra ,GA i•G 556•(916)371-5747 <br /> QUIN,LLC•14287 E.M Ave.•Parllar,CA. •CALfX102751•(559)498-0240 <br /> � AL TE <br /> USED <br /> pI„USED ANTFREEZE AND OILY WATER ARE - chat the - are classified, ,pa ,mar <br /> IRCYCLED AT OUR SISTER COMPANY DEMENNO/KERD THE40 <br /> arta am in proper condition for transportation,aarvoaV to Ite applkxible regulabom, <br /> LARGEST REcYCLER OF USED OIL IN THE WE T <br /> °I HEREBY CERTIFY THAT I HAVE NOT MIXED THIS WAStE WIM ' <br /> DTHER WASTE.THAT 7HE'T01'AI.HALIDES ARE L€ss s .ea. X <br /> AND THAT THE WASTE DOES NOT CONTAIN ANY P,C.B'S.... €+ low+.ruRE DATE <br /> -1 FURTHER AGREE TO ACCEPT THE ADDITIONAL CHARGES FOR LEGAL X <br /> DISPOSAL IF THIS WASTE IS OVER 1000 P.P.M.TOTAL HAL101i OR, PRINT NAME <br /> CONTAINS ANY PC S'S - ` - <br />