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Jan 06 2212 : 25p Payless Auto Repair 209-334-3115 p , 1 <br /> R RED <br /> SERVICE WORD <br /> Cie a n `Tech <br /> ORDER <br /> DEC 31 2021 Environmental Inc. <br /> 2581 S . Sunland Avenue • Fresno, CA 93725 3 10 <br /> ENVIRONMENTAL HEALTH Phone : 1 - 800-531 -9683 <br /> www.cleantechenvfcorn <br /> DEPARTMENT <br /> WASTE RECYCLING RECEIPT - BULK FLUIDS <br /> Name <br /> _ ' Customer Purchase Order # <br /> AddressIF , IFF, IFFIr I - Sales Representative <br /> 14 . <br /> City State Zip Phone # <br /> EPA ID # Ck # ICOD <br /> Manifest # Used Oil IF IF Manifest # Non Haz Wastewater <br /> Manifest # Used Antifreeze <br /> 3 ty y xr <br /> Mx: a pi - IF FF <br /> IF IF IF r <br /> PART # U. S . DDT SHIPPING DESCRIPTION QTY. UDM INT PRICE SUB-TOTAL <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID, CA WASTE CODE 221 GAL <br /> fx <br /> IZ '10013500 USED ANT4 FREEZE NON-RCRA HAZARDOUS WASTE LIQUID, CAWASTE CODE 135 GAL <br /> 0 <br /> �} 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> IF <br /> W Man. Fee MANIFEST DOCUMENT FEE EA . <br /> W <br /> • J <br /> IL <br /> Tff <br /> IFI IFFIA TIF <br /> U <br /> LU USED OIL CERTIFICATION : Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> 0 facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> i— that the contents 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 40 CFR 26227 <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 /> non-conforming will be subject to additional charges . <br /> r IF <br /> IF IF I <br /> X <br /> TYPE OR PRINT FULL NAME GENERATOR .SIGNATURE DATE f / <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 cemingled with other waste streams. As the Generator, I acknowledge that our site EPA ID ;I! is active. This document <br /> serves as a written verification that the waste stream (s) descriptions and constituents found above are unchanged perthe Facility Generator <br /> Waste Profile Worksheet and also as the 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 /> IF <br /> IF W <br /> . .yyy IF <br /> yY�j �y[Y <br /> . . .E <br /> IF <br /> , <br /> 1N 1 <br /> fin <br /> f <br /> CleanTech Environmental, Inc , PRINT FUjLL NAME lop <br /> s <br /> CL 2581 S. Sunland Avenue <br /> rn Fresno, CA 93725 X <br /> 14 EPA ID #: CAL000368136 DRIVER 'S SIGNATURE <br /> F <br /> I l <br /> /yam ' TANKER # <br /> DATE <br /> IF* FFI <br /> " , V -, . . IF IF IF IF <br /> . -. � •... . < zt �. ' . rt'f .. lLllr u-Y . . iii � U - _ � � _ • �4-R"S- - 5IF IF <br /> FIFF _ <br /> The checked box is the designated recycling facility. <br /> Ica t� LI CleanTech Environmental , Inc , n 5820 Martin Road , Irwindale , CA 91706 EPA ID #: CAL000330453 <br /> w ¢ '0 CleanTech Environmental , Inc , - 4910 Donovan Way, Ste. A, N . Las Vegas, NV 89801 EPA ID #: NVROOOO90050 <br /> a cc D Industial Environmental Services IF 13350 Grand Valley Parkway, N . Las Vegas, NV 92126 <br />