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SERVICE WORK <br /> kofeanTechORDER <br /> Environmental Inca <br /> 2581 S. Sunland Avenue o Fresno, CA 93725 23465 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.corn <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name Customer Purchase Order# <br /> Address ( f v� u/"—i Sales Representative <br /> City State Zip f?'f PON C"04 q;-34 Phone# <br /> EPR ID# C�A (, 0-6 d Le3 .?Y Ck#/COD <br /> Manifest# Used❑i1 (]1)06 c2 9 W I< Manifest#fon Naz Wastewater <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> Ir PART# U.S.DOT SHIPPING DESCRIPTION <br /> QTY.JUOPA I INTJ PRICE I SU8-TOTAL <br /> CIE10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 1taL GAL 1 v 1 <br /> CJW <br /> Z 10413500 USED ANTI-FREEZE NDN-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> 0 <br /> P.- 10043004 NON-HAZARDOUS WASTEWATER GAL <br /> M <br /> LUMan.Fee MANIFEST DOCUMENT FEE <br /> IEA. <br /> UJ-- T <br /> 1 <br /> D. <br /> •7,L <br /> U <br /> GENERATOR USED OIL CERTIFICATION <br /> m USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> 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 stripping name and are classified,packaged, <br /> marked, labeled and are in all aspects in proper condition for transport by D,O.1 standards.All relevant Information regarding known or <br /> suspect hazards associated with this waste have been disclosed. I certify that the waste minimization_ statem nt identified In 40 OFR 26227 <br /> (a) (if I am a large quantity generator) or(b) (if I am a small quantity generator) us true. Waste material which are discovered to be <br /> non-conforming will be subject to additional charges. <br /> H <br /> TYPE OR PRINT FULL NAME GENER qR SIGNATURE ti 1�/�� 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 m5te streams- <br /> I declare under the penalty of perjury that the foregoing is true and correct. <br /> 72581 TRANSPORTER <br /> Tech Environmental, Inc. � " :s W r'C- y <br /> .Sunland AvenuePRINT FULL NA1W>=zen , CA 93725 k, � �,t}A. (�7 <br /> EPA iD#:CAL000368136 DRIVER'S SIGNATURE <br /> F- <br /> m <br /> •' I I f 1 <br /> TANKER# DATE <br /> RECEIVING FACILITY <br /> � The eked box is the designated recycling facility. <br /> w CleanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 91705 EPA ID#:CAL000330453 <br /> cUJ ¢ ❑ CleanTech Environmental,Inc.-4910 Donavan Way, Ste.A, N.Las Vegas, NV 89801 EPA 1D#:NVROOOO90050 <br /> Cc <br /> ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br />