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RECEIVED 12/16/2021 VIA EMAIL <br />Clean"Mech <br />Environmental <br />2581 S. Sunland Ave. c Fresno, CA 93725 <br />Phone: 800-531-9683 <br />WASTE RECYCUNG RECEIPTPOSTED <br />SERVICE WORK <br />®RIDER <br />17 8 I u <br />Name: �Qr'ril�tl'>j� Customer Purchase Order # <br />Address: 3t')z N Ck e Cg kk'e Zlt <br />Sales Representative <br />City, State, Zip: -Lart i (0, 9-5 ---1 q () Phone #: <br />EPA ID #: _ (fAIZOI—O (�,�7 Federal Manifest #: �Zr✓(� CSC ��g � <br />QUANTITY UNITS U.S. DOT DESCRIPTION CHARGE <br />GAL. USED OIL – NON RCRA HAZARDOUS WASTE, LIQUID <br />CA WASTE CODE 221 <br />GAL. USED ANTI -FREEZE— NON RCRA HAZARDOUS WASTE, LIQUID <br />CA WASTE CODE 134 <br />0 GAL, <br />OILY WATER FROM USED PARTS WASH SOLUTION — <br />Q NON-RCRA HAZARDOUS WASTE, LIQUID. CA WASTE CODE 134 <br />fl" <br />W DRUM(S) DRAINED USED OIL AND GAS FILTERS <br />Z <br />W <br />� y <br />M C! ✓1 i l y� <br />0 TOTAL <br />W The above used oil is`3 <br />W %Lubricating oil %Industrial oil <br />J ACCOUNT STATUS: () C.O.D. () OPEN ACCOUNT If open Account - payment is due net 30 days or a finance charge of 1.5% <br />CL per month will apply. <br />13 <br />O GENERATOR'S NOTIFICATION AND CERTIFICATION: Any used oil that the transporter receives Irom the generator will be transported to a certified used oil recycling facility that is <br />0 lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare that the contents of this consignment are fully and <br />W accurately described above by the proper DOT shipping name and are classified, packaged, marked, and labeled and are In all aspects in proper condition for transport by D.O.T. <br />Op standards. All relevant information regarding known or suspected hazards associated with this waste has been disclosed. The customer agrees lu pdy reasonable cost and attorney <br />O fees incurred in the collection of this obligation. Venue for purposes of this obligation shall be in Los Angeles County. I certify that the waste minimization statement identified in 40 <br />f— CFR 26227(a)(if I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. I also acknowledge that I have read and agree to the terms on this form both front <br />and back. Signer guarantees the payment of CleanTech invoices in accordance with the standard terms of Net 30 days. If a Purchase Order is not issued, the employee authorizing the <br />work performed guarantees that any invoices presented will be paid promptly. Prompt payment is defined as payment in accordance with CleanTech standard terms of net 30 days. <br />Invoice payment is not contingent upon payment by a third party, Interest on past due accounts will be charged at the rate of 1.5% per month until paid in full. WASTE MATERIALS <br />WHICH ARE DISCOVERED TO BE NON -CONFORMING W E SUBJECT TO ADDITIONAL CHARGES. <br />TYPE OR PLL NAME <br />ATURE DATE <br />I hereby cern( that I have read and have the uthorily to bind the above listed generator to the ter found on both the front and back of this form, Slate Law requires that both <br />the Generator and Transporter keep this form on file for a minimum of (3) years. I hereby certify that all information in this and all attached documents contain true and accurate <br />descriptions of the waste including that the waste is segregated and is not cominglod with other waste streams. As the Generator, I acknowledge that our site EPA ID R is active. The <br />waste stream listed above complies with the Waste Profile on record for the designated Facility. This document serves as written verification that the waste stream(s) description <br />and constituents found above are unchanged per the Facility Generator Waste Profile Worksheet and also acls as the annual written verification for the Generator Waste Profile <br />Worksheet of these waste streams. I declare under penally of perjury that the foregoing is true and correct. <br />Lu <br />w <br />CleanTech Environmental Inc. <br />2581 S. Suniand Ave. <br />O <br />0 <br />Fresno, CA 93725 <br />, <br />J <br />ZEPA <br />ID #: CAL000368136 <br />D IV R'S NAME -TYPE OR PRINT FULL NAME <br />< <br />�' <br />Truck, Unit ID No. <br />% <br />1,%�� <br />SIGNATOR <br />DATE <br />The checked box is the designated <br />recycling facility <br />F H <br />❑ Roadrunner Glycol, Inc. <br />❑ Southwest Processors <br />❑ Heritage Environmental <br />U � <br />X U U <br />4636 Industrial Center Dr. <br />Las Vegas, NV 89115 <br />4120 Bandini Blvd. <br />Services LLC <br />tech <br />Martin nRd. Environmental <br />Q <br />ILL! c W <br />EPA # NVR000088427 <br />Ph <br />Vernon, CA 90058 <br />EPA # CAL921646037 <br />284 East Storey Road <br />Coolidge, AZ 85128 <br />Irwindale, CA 91706 <br />EPA # CAL000330453 <br /># 702/379-7179 <br />Ph # 800/900-3366 <br />EPA # AZD081705402 <br />Ph # 626/812-7200 <br />Ph # 520/723-4167 <br />