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Received on 01/03/222 SERVICE WORK <br /> - CleanTec — ODDER <br /> Environmental Inc. ; <br /> 2581 S.Sunland Avenue• Fresno, CA 93725 <br /> Plnone: 1-800-531-9683 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name Customer Purchase OrdOT# <br /> i. :a y iLT <br /> Address Sales Representative <br /> City State Zip Phone <br /> EPA ID# Ck#1 COD ' <br /> Manifest#Used Oil Manifest#Non Haz Wastewater <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> or PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> OGAL <br /> Q10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> 2' <br /> 10013500 USED ANTI-FREEZE NON•RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> W <br /> GAL <br /> 10043000 NON-HAZARDOUS WASTEWATER <br /> m <br /> 0 Man.Fee MANIFEST DOCUMENT FEE EA. <br /> LU - <br /> 1•- <br /> UA <br /> ..r <br /> GENERATOR USED Olt_CERTIFICATION <br /> 0 <br /> U <br /> LU <br /> rfacifity <br /> D Olt.CERTIFICATION:Any used oil that the transporter receives from the generator wilt be transported to a certified used oil recycling <br /> O that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> 227 <br /> ked, labeled and are in all aspects in proper condition for transport by O.O.T. standards.All relevant information regarding known or <br /> 227 <br /> suspect hazards associated with this wast have lb been discsma I I certify <br /> that <br /> waste <br /> minimizationste statement <br /> idi n ified discovered�n 40zto be <br /> 227 <br /> (a) (if I am a large quantity generator) or {b) (' 4 h+ generator) <br /> non-conforming will be subject to additional charges. <br /> X <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE <br /> I hereby cerlify 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 comingied with other waste streams.As the Generator, I acknowledge that our site EPA Ib#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 annus{written verification for the generator waste stream profile worksheet of these waste streams. <br /> declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> UJt <br /> CleanTech Environmental,Inc. PRINT FULL NAMEcc <br /> J� <br /> O 2581 S.Sunland Avenue , <br /> rn Fresno, CA 93725 x <br /> DRIvE5R,S SIGNATURE <br /> EPA ID #:CAL000368136 f' <br /> ~ % <br /> TANKER# DATE <br /> RECEIVING FACILITY <br /> W 2 _r The checked box is the designated recycling facility. <br /> En p CleanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 91706 EPA ID #:CAL000330453 <br /> � � U <br /> X <br /> 0 © CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, N 89801 EPA ID#: 0 0090050 <br /> a R ❑ Indusia a] Environmental Services 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br /> e <br />