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rc <br />!R <br />cc <br />LU <br />Z <br />W <br />0 <br />} <br />M <br />0 <br />W <br />I— <br />W <br />J <br />a. <br />0 <br />0 <br />r.0 <br />In <br />0 <br />RECEIVED 12/1612021 _VI_A EMAIL <br />===LieantecnSERVICE WORK <br />ORDER <br />Environmental Inc. <br />r, 2581 S. Sunland Avenue o Fresno, CA 93725 �° `� <br />23165 <br />Phone: 1-800-531-9683 <br />www.cleantechenv.com <br />Name <br />%• � Customer Purchase Order # <br />Address <br />- G L <br />City State Zip <br />EPA ID #�� <br />Manifest # Used Oil <br />Sales Representative <br />Phone # <br />Ck # / COD <br />Manifest # Non Haz Wastewater <br />Manifest # Used Antifreeze) <br />SHIPPING INFORMATION <br />PART # U.S. DOT SHIPPING DESCRIPTION <br />10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID, CA WASTE CODE 221 <br />10013500 USED ANTI - FREEZE NON-RCRA HAZARDOUS WASTE LIQUID, CA WASTE CODE 135 <br />10043000 I NON -HAZARDOUS WASTEWATER <br />Man. Fee I MANIFEST DOCUMENT FEE <br />CITY.LOMI INT PRICE I SUB -TOTAL <br />710 1 GAL 1 17Ot1 <br />GENERATOR USED OIL CERTIFICATION <br />GAL <br />GAL <br />EA. y <br />USED OIL CERTIFICATION: Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br />facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br />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.D.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-coof min will be ubject to additional charges. <br />TYPE OR PRINT FULL NAME GENERATOR SIGNATURE <br />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 />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 comingled with other waste streams. As the Generator, I acknowledge that our site EPA ID # 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 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 />cc <br />W <br />I" CleanTech Environmental, Inc. <br />LEPA <br />Sunland Avenue <br />CA 93725 <br />: CAL000368136 <br />TRANSPO <br />X�1 <br />DB S SIGNATURE <br />joy <br />DATE <br />o Z RECEIVING FACILITY <br />w <br />1Z The checked box is the designated recycling facility. <br />J <br />a w v . � IeanTech Environmental, Inc. - 5820 Martin Road, Irwindale, CA 91706 EPA ID #: CAL000330453 <br />LU UJ LL LJ <br />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 />