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SERVICE WORK <br /> � CleanTech ORDER <br /> Environmental Inc. <br /> 2581 S.Sunland Avenue o Fresno, CA 93725 23456 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.coln <br /> TASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Mame �' �7�� Customer Purchase Order# <br /> Address r S i5' t ►v-� Sales Representative <br /> City State Zip p,,ia6,4CA of S 3 U Phone# <br /> EPA ID # CA L&, L -71 Ck#1 COD <br /> Manifest#Used Oil I I r � Manifest#Nan Haz Wastewater <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> x PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> 10U2210o USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 �(�� GALEr <br /> G <br /> Lel <br /> W 1(1013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> C7 <br /> 10043004 NOH-HAZARDOUS WASTEWATER GAL <br /> to <br /> 0 Man.Fee MANIFEST DOCUMENT FEE E4.LU <br /> F- <br /> LU <br /> J 7 <br /> 0 GENERATOR USED OIL CERTIFICATION <br /> UJ 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 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 identilied in 40 CFR 26227 <br /> (a) (if I am a large quantity generator) or(b) {if I am a smal an*general us true. Waste materials which ara discovered to be <br /> non-conforming will be subject to additional charges. <br /> TYPE OR PRINT FULL NAME GENEA#OR SIGNATUR DATE <br /> I hereby certify that 1 have read and have the au ority to bind the above listed generator to the terms found on the Irornl 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 camingled 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 /> CleanTech Environmental*Inc. <br /> cc PRINT FULL NAME <br /> ❑ 2581 S.Sunland Avenue <br /> WFresno,CA 93725 x <br /> a EPA ID#:CAL00036813t3 QRIVER'SSrGNATURE <br /> � <br /> TANKER# Y r DATE <br /> ra ❑ } r RECEIVING FACILITY <br /> The c eked box is the designated recycling facility. <br /> ui D IeanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 91705 EPA ID#:CAL000330453 <br /> Cr. <br /> L< © CleanTech Environmental,Inc.-4914 Donovan Way, Ste.A, N.Las Vegas,NV 89801 EPA ID*NVROOOD90050 <br /> 0- ❑ industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br />