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SERVICE WORK <br /> � CleanTech :__ ORDER <br /> Environmental inc. <br /> 2581 S.Sunland Avenue o Fresno, CA 937253443 <br /> — Phone: 1-800-531-9683 <br /> ww w.cl ea n to ch env.com <br /> TASTE RECYCLM RECEIPT-BULK fFLUMS <br /> Name Customer Purchase Order# <br /> Address t 5715 14.6r-7c Vy'-,.c Sales Representative <br /> City State Zip [Z,&A,f , Phone# <br /> EPA ID# "LGa[� y j 7 7 Clc#I GOD <br /> Manifest# Used Oil - 6 U 1 Manifest# Non I-Iaz Wastewater <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> cc PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> 100221OU USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 Lit GALcc <br /> w <br /> Z 10013500 USED ANTIFREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> LU <br /> C7 <br /> 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> UJ <br /> Man.Fee MANIFEST DOCUMENT FEE EA. cls <br /> F- <br /> w <br /> U GENERATOR USED OI!_CERTIFICATION <br /> USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> °a 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 classilied,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 417 CFR 26227 <br /> (a) (if I am a large quantlty generator) or (b) (it 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 /> T�LJ lvl, �`�"Lj f x •c%�� �a zf 1 2 c�� <br /> TYPE OR PRINT FULL NAME �� GEY RATOH SIGNATURE DATE <br /> I hereby certify that I have read and have the authority o`bind the above fisted genfera or tothe terms found on the front and the back of <br /> this form. I hereby certify this,and all attached documbnts 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 r'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 Proti le Worksheet and also as tale 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 /> Ul <br /> GleanTech Environmental,Inc. PRINT FULL NAME <br /> a 2581 S.Sunland Avenue , <br /> CL Fresno, CA 93725 Xr �,. <br /> Z EPA ID#:CAL000368136 DRIVER'S SIGNATURE <br /> cc <br /> _ t ( 12-3 1?r� <br /> TANKER ��- DATE <br /> C3 RECEIVING FACILITY <br /> ah Th e�flecked box is the designated recycling facility. <br /> O'CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91708 EPA 1D#:CAL000330453 <br /> CC <br /> Lu L 11 CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A,N.Las Vegas,NV 83801 EPA ID 4:NVROOOO90050 <br /> M. a J Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br />