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--: (C#a C,-- <br /> IJ L1 USERVICE WORK <br /> ORDER <br /> Environmental do ca <br /> 2581 S.Sunland Avenue - Fresno, CA 93725 23182 <br /> Phone: 1-800-531-9683 <br /> vu w vv.cl e a rite c h env,co rn <br /> WASTE RECYC NG RECEW U•BULK FLUMS <br /> Name �� tC Customer Purchase Order# <br /> Address �I' Sales Representative <br /> City State Zip J <br /> Phone# <br /> EPA ID # �i —7--7 Ck#/COD <br /> Manifest# Used Oil f 1 � rr 3 I I v Manifest#Non I�az Wastewater <br /> "3a <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> D PAAT# U.S.DOT SHIPPINGa DESCRIPTION CITY. UOM INT PRICE SUB-TOTAL <br /> q10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> W <br /> W 10013500 USED ANTkFI1EEZ5 NON•RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> 0 <br /> >. 14043000 NON-HAZARDOUS WASTEWATER GAL <br /> Man.Fee MANIFEST DOCUMENT FEE ` <br /> l EA. yf <br /> a. <br /> U GENERATOR USED OIL CERTIFICATION <br /> UJI C13 USED-Q1L CERTIFICATION:Any used off that the transporter receives from the generator will be transported to a certified used oil recycling <br /> fac!llty ttgt is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act.I hereby declare <br /> that thi,eoiitents 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 identified in Ott CFR 26227 <br /> (a) (if l am a large quantity generator) or(b) (if I am a small quantity generator) us true. Waste materials which are discovered to be <br /> non-c forming will be subject to additional charges. <br /> r1�' <br /> TYPE OR PRINT FULL.NAME GEN RATOR SIGN RE DATE <br /> I hereby certify that I have read and have the authority to bind the abov isted generator to the terms found on the front and the back of <br /> this form. I hereby certify this,and all attached documents contain tru and accurate descriptions of the waste including Ihat the waste is <br /> segregated and not c0m1n9led with other waste streams.As the Generator, I acknowledge that our site EPA la#is active.This document <br /> serves as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the Fatality Generator <br /> Waste Profile Worksheet and also as the annuai written verification to 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 /> cc TRANSPORTER <br /> r`u— <br /> CleanTech Entiirvnmental,lnc. <br /> 0 2581 S.Sunland Avenue PRINT URL N M <br /> Fresno, CA 93725 H <br /> Q EPA ID #:CAL000368136 DRII��V]F sf IG}NAT�UyRE <br /> ! ! "a <br /> TANKER N DATE <br /> RECEIVING FACILITY <br /> The checked box is the designated recycling facility. <br /> El U F-W-61eanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID M CALOOD330453 <br /> w <br /> tu w 0 CleanTech Environmental,Inc.-4910 Donovan Way,Ste.A, N.Las Vegas, NV 89801 EPA ID#:NV9000090050 <br /> CL °C 0 Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas,NV 92126 <br />