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p ' <br /> FOR SERVICE CALL: ORDER <br /> DIXON OFFICE RECEVE.DMICE <br /> 1-800-7-ASBURr SERVICE ORDER NO. <br /> FRESNO 0 C T 2 3 2014 <br /> 559-498-0240 . <br /> �-c = <br /> CHICO OFFICE �vTAL HEALTI <br /> 300-733-9043 ENVIRONMENTAL yy�,,TT <br /> DEPAa'���EI BURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE, COMPTON,CA 90221 <br /> It t 1-310-886-3400 <br /> i, <br /> TRANSPORTER EPA#CAD0282.77036 <br /> U <br /> r) <br /> CUSTOMER# PURCHASE ORDER# f_A6Ufff#j TRUCK# CONTACT NAME ORDER TAKEN BYHALIDES <br /> DATE REQUIRED DATE=ENTERED NEXT SERVICE DATE CUSTOMER EPA# MANIFEST# <br /> PART# DESCRIPTION QTY UNIT PRICE QTY PIU TOTAL <br /> TOTAL <br /> CASH RECD: CHECK# PLEASE PAY FROM THIS SERVICE ORDER <br /> WASTE DISPOSAL INFORMATION <br /> T NON-RCRA HAZARDOUS WASTE,LIQUID(USED OIUMIXED 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: 33210 Western Avenue,Union City,CA 94587 1-510-487-9277 <br /> DRUMS PN: EMPTY DRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> t his 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 <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)I 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.1 have <br /> nmphed with Ilia 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 /> I the information 1 have provided about this waste Is incorrect <br /> 02)l have not mixed any o1 the waste described above with any other nazardous waste,the total halide content is GREATER(Iran 1,000 ppm,and the waste does not contain any PCBs.I <br /> ave provided proper documentation to Asbury Environmental Services to robot(tie presumption that this waste was mixed with other hazardous waste.I agree to accept the additional charges <br /> n the disposal of this waste if the information 1 have provided about this waste is incorrect <br /> a3)This waste is front a tank which collects waste oil from household"do-it-yourself"(DIY)and/or conditionally exempt small quantity generator(CESDG)sources.To the best of my <br /> ,iowiedge,the only waste oil contained in my DIY!CESOG collection tank Is soley from DIY and/or CESGG sources.1 have not mixed this waste oil with any other hazardous waste or <br /> Isle oil from other sources.1 agree to accept the additional charges for disposal of this waste if the information I have provided about this waste is incorrect <br /> (All generators/customers MUST read the following text and check the associated box.) <br /> itq) <br /> III 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 /> acticable and that I have 30l6CtQd the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human lite and <br /> .n environment;9r,if I am a small quantity generator,I have made a good faith effort to minimite my waste generation and select the best waste management melhad that is available <br /> nie that 1 can afford. <br /> r � <br /> t.Istorner,Signature ? ' Date Driver Signature Date <br /> rint Name <br />