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CI e a n T SERVICE WORK <br /> e ch ORDER <br /> Environmental Inc. <br /> 2581 S. Sunland Avenue • Fresno, CA 93725 20303 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT- BULK FLUIDS <br /> Name Customer Purchase Order # <br /> Address Sales Representative <br /> City State Zip Phone # <br /> EPA ID # Ck #/ COD <br /> Manifest # Used Oil Manifest # Non Haz Wastewater <br /> Manifest # Used Antifreeze <br /> SHIPPING INFORMATION <br /> cc PART# U.S. DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> ccW <br /> �Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> C� <br /> �. 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M <br /> 0 Man.Fee MANIFEST DOCUMENT FEE EA. <br /> W <br /> H <br /> W <br /> J <br /> a <br /> o GENERATOR USED OIL CERTIFICATION <br /> W USED OIL CERTIFICATION: Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> 00 facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> marked, labeled and are in all aspects in proper condition for transport by D.O.T. standards. All relevant information regarding known or <br /> suspect hazards associated with this waste have been disclosed. I certify that the waste minimization statement identified in 40 CFR 26227 <br /> (a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) us true. Waste materials which are discovered to be <br /> non-conforming will be subject to additional charges. <br /> X <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE <br /> I hereby certify that I have read and have the authority to bind the above listed generator to the terms found on the front and the back of <br /> this form. I hereby certify this, and all attached documents contain true and accurate descriptions of the waste including that the waste is <br /> segregated and not comingled with other waste streams. As the Generator, I acknowledge that our site EPA ID # is active. This document <br /> serves as a written verification that the waste stream (s) descriptions and constituents found above are unchanged per the Facility Generator <br /> Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams. <br /> I declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> cc <br /> W <br /> ~ CleanTech Environmental, Inc. <br /> PRINT FULL NAME <br /> a 2581 S. Sunland Avenue <br /> N Fresno, CA 93725 X <br /> EPA ID #: CAL000368136 DRIVER'S SIGNATURE <br /> er <br /> TANKER# DATE <br /> W } RECEIVING FACILITY <br /> The checked box is the designated recycling facility. <br /> w v ❑ CleanTech Environmental, Inc. - 5820 Martin Road, Irwindale, CA 91706 EPA ID #: CAL000330453 <br /> w w LI CleanTech Environmental, Inc. - 4910 Donovan Way, Ste. A, N. Las Vegas, NV 89801 EPA ID #: NVR000090050 <br /> a CC ❑ Industial Environmental Services - 13350 Grand Valley Parkway, N. Las Vegas, NV 92126 <br />