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FOR SERVICE CALL: SERVICE ORDER <br /> FORM NO AES004-B(REV 8/15) <br /> DIXON OFFICE <br /> 1-800-7-ASBURY _ SERVICE ORDER NO. <br /> FRESNO <br /> 559-498-0240 — –—_ <br /> CHICO OFFICE <br /> 800-733-9043 <br /> ASBURY ENVIRONMENTAL SERVICES <br /> S 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> It 1-310-886-3400 <br /> P TRANSPORTER EPA#CAD028277036 <br /> P <br /> E <br /> D <br /> T <br /> O <br /> CUSTOMER# PURCHASE ORDER# ROUTE# 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 /> TOTAL <br /> CASH REC'D: CHECK# <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: <br /> ALTERNATE TSDF: <br /> SA RECYCLING: 23285 Eichler,Ste.E,Hayward,CA 94541 323-921-4784 <br /> DRUMS PN: EMPTY DRUMS: FACILITY: BS C <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> 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 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 /> ❑ <br /> 41)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 CeBlmmia 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 /> D#2)1 have not mixed any of the waste described above with any other nazardous 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(hat 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 /> D#3)This waste is from a tank which collects waste oil from household"do-it-yourself'(DIV)and/or conditionally exempt small quantity generator(CESOG)sources.To the best of my <br /> knowledge,the only waste oil contained in my DIV/CESOG collection tank is soley from DIY and/or CESOG 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 the information 1 have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> '-D 94)If 1 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 I have determined to be economically <br /> practicable 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 /> the environment;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. _ r <br /> Customer Signature Date DriY6rSlgnature -Date <br /> I <br /> Print Name Print-drivers Name <br />