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r it W cc O CL rn Z a It H Do tWZ>_ SUV W W LLa. CIL Cc Name: Address: =CieanTech=== Environmental Inc. 2581 S. Sunland Ave. • Fresno, CA 93725 Phone: 800-531-9683 WASTE RECYCLING RECEIPT SERVICE WORK ORDER Customer Purchase Order # Sales Representative City, State, Zip: ?' Phone #: EPA ID #: Federal Manifest #: QUANTITY UNITS U.S. DOT DESCRIPTION CHARGE DATE GAL. USED OIL — NON RCRA HAZARDOUS WASTE, LIQUID ❑ Heritage Environmental d0leantech Environmental Services LLC CA WASTE CODE 221 284 East Storey Road Irwindale, CA 91706 GAL. USED ANTI -FREEZE — NON RCRA HAZARDOUS WASTE, LIQUID EPA # AZD081705402 Ph # 626/812-7200 Ph # 520/723-4167 CA WASTE CODE 134 GAL. OILY WATER FROM USED PARTS WASH SOLUTION — NON-RCRA HAZARDOUS WASTE, LIQUID. CA WASTE CODE 134 DRUM(S) DRAINED USED OIL AND GAS FILTERS TOTAL The above used oil is % Lubricating oil % Industrial oil ACCOUNT STATUS: () C.O.D. () OPEN ACCOUNT If open Account - payment is due net 30 days or a finance charge of 1.5% per month will apply. GENERATOR'S NOTIFICATION AND CERTIFICATION: Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling facility that is 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 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. standards. All relevant information regarding known or suspected hazards associated with this waste has been disclosed. The customer agrees to pay reasonable cost and attorney 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 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 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 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. 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 WHICH ARE DISCOVERED TO BE NON -CONFORMING WILL BE SUBJECT TO ADDITIONAL CHARGES. TYPE OR PRINT FULL NAME SIGNATURE DATE I hereby certify that I have read and have the authority to bind the above listed generator to the terms found on both the front and back of this form. State Law requires that both 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 descriptions of the waste including that the waste is segregated and is not comingled with other waste streams. As the Generator, I acknowledge that our site EPA ID # is active. The 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 and constituents found above are unchanged per the Facility Generator Waste Profile Worksheet and also acts as the annual written verification for the Generator Waste Profile Worksheet of these waste streams. I declare under penalty of perjury that the foregoing is true and correct. CleanTech Environmental Inc. 2581 S. Sunland Ave. Fresno, CA 93725 EPA ID #: CAL000368136 Truck, Unit ID No. The checked box is the designated recycling facility ❑ Roadrunner Glycol, Inc. 4636 Industrial Center Dr Las Vegas, NV 89115 EPA # NVR000088427 Ph # 702/379-7179 ❑ Southwest Processors 4120 Bandini Blvd. Vernon, CA 90058 EPA # CAL921646037 Ph # 800/900-3366 DRIVER'S NAME -TYPE OR PRINT FULL NAME SIGNATURE DATE ❑ Heritage Environmental d0leantech Environmental Services LLC 5820 Martin Rd. 284 East Storey Road Irwindale, CA 91706 Coolidge, AZ 85128 EPA # CAL000330453 EPA # AZD081705402 Ph # 626/812-7200 Ph # 520/723-4167