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=-- C �leanTech <br /> SERVICE WORK <br /> ORDER <br /> Environmental Inc. <br /> H7LP,P [DD2581 S. Sunland Avenue• Fresno, CA 93725 18398 <br /> Phone: 1-800-531-9683 <br /> www.cl ea Cytec he nv.c o m <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name r -{ FU S&z�-p C Customer Purchase Order# <br /> Address S'i 5— •_-flo iz=r fLk V Sales Representative <br /> City State zip /fitUN . C)5 3 G Phone # <br /> LPAi13 # � � 7 Ck #/COD <br /> Manifest#Used Oil 0300 118 C, 7 "/-A-s Manifest# Non Haz Wastewater <br /> Manifest #Used Antifreeze <br /> SHIPPING INFORMATION <br /> a PART# U.S.DOT SHIPPING DESCRIPTION QTY. UCM INT PRICE SUB ICTAL <br /> cc 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> 131 <br /> W 10013500 USED ANTI-FREEZE NON.RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> (5 <br /> >_ 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M <br /> 0 Man.Fee MANIFEST DOCUMENT FEE EA.LLJ <br /> �,- <br /> >J1 <br /> 0. <br /> 0 GENERATOR USED OIL CERTIFICATION <br /> ua USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> m 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 DCT shipping name and are classified, packaged, <br /> marked, labeled and are In all aspects in proper condition for transport by C.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 44 CFR 26227 <br /> (a) (if I am a large quantity generator) or (b) (if I am a small q antity generator) us true. Waste materials which are discovered to be <br /> non-conforming will be subject to additional charges. <br /> TYPE OR PRINT FULL NAME GEN GNATURE 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 farm. I hereby certify thls,and all attached documents contain true and accurate descriptions of the waste including that the waste is <br /> segregated and not cQmingled with other waste streams. As the Generator, I acknowledge that our site FPA ID#is active. This document <br /> serves as a written verification thatthe waste stream (s) descriptions and constituents found above are unchanged perthe 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 /> 1 declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> M <br /> LU <br /> CleanTech Environmental* Inc, "A <br /> pill AAA VV/ <br /> � <br /> O 2581 S. Sunland Avenue J ,] <br /> Cn Fresno, CA 93725 X <br /> a EPA ID#: CAL000368136 DRIVER'S SIGNATURE <br /> r— a 2C <br /> TANKER M t 3 DATE <br /> } RECEIVING FACILITY <br /> Thec�ecked box is the designated recycling facility. <br /> g vU t3rCleanTech Environmental,Inc.-5820 Martin toad, Irwindale,CA 91706 EPA ID #:CAL000330453 <br /> W 14 LlCleanTech E=nvironmental, Inc.-4910 Donovan Way, Ste.A. N.Las Vegas, NV 89801 EPA ID #:NVR000090050 <br /> a Cr ❑ Industial Environmental Services - 13350 Grand Valley Parkway, N. Las Vegas, NV 92126 <br />