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der✓ z0 2ozl �, <br />IIZ(p., \jI.- I':\L IIFAETI -I <br />Cge a 6T e c — SERVICE ORDERORI� <br />LI <br />Environmental Inc. <br />2581 S. Sunland Avenue • Fresno, CA 93725 <br />23165 <br />Phone; 1-800-531-9683 <br />www.cleantechenv.com <br />WASTE RECYCLING RECEIPT -BULK FLUIDS <br />Name Customer Purchase Order # <br />Address ` Sales Representative <br />City State Zip Phone If <br />EPA ID #3 Ck#/COD <br />Manffest # Used Oil 3UQ 3() L(/ Manifest If Non Haz Wastewater <br />Manffest # Used Antifreeze <br />SHIPPING INFORMATION <br />cccc PART # U.S. DOT SHIPPING DESCRIPTION <br />CITY. UOM INT PRICE SUB -TOT <br />S10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID, CA WASTE CODE 221 Z0i GAL <br />IZ 10013500 USED ANTIFREEZE NON-RCRA HAZARDOUS WASTE LIQUID, CA WASTE CODE 135 GAL 7 <br />0 <br />M 10043000 NONHAZARDOUS WASTEWATER GAL <br />W Man. Fee MANIFEST DOCUMENT FEE <br />W / <br />J <br />0 Asa <br />GENERATOR USED OIL CERTIFICATION <br />w USED OIL CERTIFICATION: Any used oil that the transporter receives from the generator will be transported to a certified used oil <br />ycling <br />00 facility that is lawfully operating In accordance with a hazardous waste facilities permit issued pursuant to the Federal Ac. I hereby des are <br />that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are ciassiged, packaged, <br />marked, labeled and are to 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 1 am a large quantity generator) or (b) (it (am a small quantity generator) us true. Waste materials which are discovered to be <br />nwo conf In will be subject to addNonal charges. <br />l�� <br />TYP OR PRINT FU L NAME X _ eeo 1 ,S )jGENERATOR SIGNA RE DATE <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 />itis form, l 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 ID f is active. This document <br />serves as a written verification that the waste stream (s) descriptions and constituents found above are unchanged per the Ncllity Generator <br />Waste Profile Worksheet and also as the annual written verification forthe generator waste stream profile worksheet of Ihesewaste streams. <br />1 declare under the penalty of perjury that the foregoing Is true and correct. <br />ir TRANSPOR R <br />Lu <br />CleanTech Environmental, Inc.4 j <br />0 2581 S. Sunland Avenue PRINT LL NAME <br />a. <br />Z Fresno, CA 93725 X <br />EPA ID If: CAL000368136 o s SIGNATURE <br />In <br />~DA <br />TANKER# <br />c r, RECEIVING FACILITY <br />W� <br />� <br />The checked box is the designated recycling facility. <br />a w o CleanTech Environmental, Inc. - 5820 Martin Road, Irwindale, CA 91706 EPA ID M CALOOOSS0453 <br />a 0 LL ❑ CleanTech Environmental, Inc. - 4910 Donovan Way, Ste. A, N. Las Vegas, NV 89801 EPA ID #; NVR000090050 <br />❑ Industial Environmental Services -13350 Grand Valley Parkway, N. Las Vegas, NV 92126 <br />