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P. <br /> FOR SERVICE C FL; jV Lai SERVICE ORDER <br /> DIXON OFFICE hoR10C AE ooa-B(REvB'15) <br /> 1-800-7-ASBURY SERVICE ORDER NO, <br /> FRESNO NOV 2 5 2015 _- <br /> 559-498-0240 — _ <br /> CN1CC OFFICE _NVIRONMENTA <br /> ,000-733-3043 taFalTu nP�pnRTMFNT <br /> ASBURY ENVIRONMENTAL SERVICES <br /> s 1300 SOUTH SANTA FE,COMPTON,CA 90221 <br /> H 1-310-886-3400 <br /> I 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'PtV'j TOTAL <br /> I <br /> 1 <br /> i <br /> TOTAL I <br /> tCCASH REC'D: CHECK# <br /> WASTE DISPOSAL INFORMATION <br /> 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 Av6nue.Union CITY, CA 9-1587' 1 51 Q-E7-3277 <br /> DRUMS PIU: EMPTYDRUMS: FACILITY: BSC <br /> GENERATOR WASTE CERTIFICATION <br /> PLEASE CHECK THE APPROPRIATE BOX <br /> This Is to certify that the waste described above is properly classified,describedpackaged,marked and labeled,and is in proper condition for trares;wrtatwn,atcordhtg to applicable State <br /> and federal regulations,By signing below I also hereby cwlify that: <br /> (Waste oil generator/customer MUST check ONE of the following three boxes) <br /> ❑A"1)I have not rnixed any at the waste described above with any other hazardous waste,the total halide content is LESS than 1 Oar)ppm,and the waste does not contain ary PCBs.I have <br /> complied with the requirements of the applicable Cahfemia used oil management regulations to determine this s true I agree to accept the additionacharges for the disposal of this waste <br /> if the information t have provided about this waste is incorrect <br /> ❑4211 have not mixed any of the waste descrioed above with any ether hazardous waste,the total halide content is GPFATFR than 1.000 ppm,and the waste does not cortair arty PCBs.I <br /> have provided proper dUcLatentatien to Asbury Environmental Services to rebut the presumption that this waste was m,xed with other hazardous waste I agree to accept the additional charges <br /> for the disposal of this waste it the information I have provided about this waste is incorrect <br /> ft31 This waste is from a tank which collects wasto oil from household"do-it-yourself'(Dry)andlor conditionally exempt small quantity generator(CESCGP sources.To the hest of rrh' <br /> knowledge,the only waste oil contained in my❑Iv;CESQG collection tank is soley from DIV 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 it the.information I havo provided about this waste is incorrect <br /> (All generators/customers MUST read the following tent and check the associated box.) <br /> C a4) It I am a large quantity gonerator,I certify that I have a program in piece to roduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> prarticahie and that I nave selected the practicable,method or treatmeni,storage,or disposal currently available to me which minimizes the present and luture threat to human life and <br /> the environment;Or,it I am a small quantily generator,!have made a good faith effort to mintml_,e my waste generation and select the best waste management method that is available <br /> __w me that I con arlord. <br /> Customer Signature Date Driver Signature Date <br /> Print Name Print Drivers Name <br />