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�1 <br /> ;: • SERVICE WORK <br /> C§sanyech ORDER 6 <br /> ' Environmental Inc. <br /> 2581 S. Sunland Avenue • Fresno, CA 93725 30161 <br />© : Phone: 1-800-531-9683 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name r•�. .,• Customer Purchase Order# <br /> © Address .,,,,; �, Sales Representative <br /> f r City State Zip f," Phone # <br /> EPA ID # L Ck#/COD <br /> Manifest# Used Oil �" �� `, , - Manifest# Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION i <br /> CC PART# U.S.DOT SHIPPING DESCRIPTION OTY. UOM INT PRICE SUB-TOTAL <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 ^� GAL <br /> 4. cc <br /> W <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GALLU <br /> I(j <br /> >. 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M <br /> W Man.Fee MANIFEST DOCUMENT FEE I EA. <br /> a <br /> 0 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 recycling <br /> i 0 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.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 is <br /> f'✓��, (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 k <br /> . j non-conforming will be subject to additional charges. <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE 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 />•t;�:;, :; TRANSPORTER <br /> Cr <br /> 0: ' LU�• CleanTech Environmental Inc. <br /> 0= P,.pINT FULL NAME � <br /> I a 2581 S. Sunland Avenue <br /> rn Fresno, CA 93725 X <br /> Z DRIVER'S SIGNATURE /. 1 <br /> < EPA ID #:CAL000368136 1 , 1 / I <br /> 1 TANKER# _ 7T%/ DATE —T <br /> RECEIVING FACILITY <br /> LU Z F- The checked box is the designated recycling facility, <br /> i w �Q CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID #:CAL000330453 <br /> cc v a ❑ CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID#:NVR000090050 <br /> a ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br /> 0 <br />