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rc SERVICR WORK <br /> ch, <br /> ORDER <br /> 1 n YJronmen i-21 §n c. <br /> ' 17I i� r:ii <br /> f _ 2581 S.Sunland Avenue a Fresno, CA 93725 <br /> Phone. 1-800-531-9683 IJr <br /> 84 <br /> www-clew ntechenv.co m <br /> Name <br /> Customer Purchase Order# <br /> Address <br /> Sales Representative <br /> City State zip � <br /> Phone# <br /> EPA ID Ll )>2-:� Gk It/CDD <br /> Manifest#Used Oil <br /> 03001-3 5Y3 Manifest#Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> SHIPPMNG INFC3RMATION <br /> D FART# U.S.DOT SHIPPING DESCRIPTIONC>?TY• UOM INT PRICE 5U13-TOTAL <br /> Ir <br /> q 10022100 USED OIL NON RCFIA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> GAL <br /> ILI <br /> 70013500 USED grJThFREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE f35 GqL <br /> NC0 <br /> p 10043000 NON-HAZARnOUS WASTEWATER <br /> GAT_ <br /> W Man,Fee MANIFEST DOCUMENT FEE <br /> F <br /> W EA. <br /> 74 <br /> 0 75 <br /> 0o GENERATOR USED OIL CERTIFICATION <br /> Ul USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used ail recycling <br /> O facility that is lawfully Operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act.I hereby declare <br /> 1— that the contents of this consignment are fully and accurately described above by the proper OOT 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 ideatitied in 40 CFR 28227 <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 /> nonconforming will be subject to additional charges. <br /> ff <br /> Ir := L� H <br /> TYPE OR PRINT FUf L NAME] GENERATOR SIGNATURE <br /> ARTS <br /> I hereby certify that I have read and have the authority to bind the above listed generator to the terms found on the from and the back of <br /> IN s 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 10 4 is active.This document <br /> serves as a written verification that the waste stream(s)descriptions and Generator <br /> constituents found above are unchanged per the Facility <br /> Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these crane streams_ <br /> I declare under the penalty of perjury that the foregoing Is true and correct. <br /> TRANSPORTER <br /> La ell <br /> F- CleanTech Environmental, Inc, f�5 V1/,`LCA <br /> CL <br /> PRINT F <br /> 2581 S.Sunland Avenue UL <br /> L NAME <br /> Fresno, CA 93725 x <br /> < EPA ID#:CAL000368136 T <br /> DRIvaR•s SIGN E <br /> TANKER# 7 �✓ <br /> DATE <br /> RECEIVING FACILITY <br /> The checked box is the designated recycling racility, <br /> aw 9rEfe2nTech Environmental,Inc.-5820 Martin Road,Irwindale, CA 51706 EPA ID#:CAL000330453 <br /> U ❑ CleanTech Environmental,Inc,-4910 Donovan Way,Ste,A,N.Las Vegas,NV 89801 EPA ID#:NVA000090050 <br /> 0 Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas,NV 92126 <br />