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SERVICE WORK , <br /> Cgean <br /> Tech <br /> ORDER <br /> C� <br /> 3:= Environmental Inc. <br /> 31316 / <br /> I. <br /> 2581 S. Sunland Avenue • Fresno, CA 93725 <br /> Phone: 1-800-531-9683 <br /> WWW.cleantechenv.COM <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> I: Name Customer Purchase Order# <br /> AddressSales Representative <br /> i <br /> : City State Zip -� Phone # �^ <br /> EPA ID # 1 � Ck #/COD <br /> Manifest# Used OilManifest# Non Haz Wastewater2-12 ,71 <br /> • / '— Iii �- <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> o PART#cc <br /> U.S.DOT SHIPPING DESCRIPTION QTY. UOM INTI PRICE SUB-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 > GAL ( l <br /> wcc <br /> F <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL til <br /> w <br /> I. 10043000 NON-HAZARDOUS WASTEWATER <br /> GAL fI <br /> W Man.Fee MANIFEST DOCUMENT FEE <br /> E..- EA. <br /> _J <br /> CL <br /> 2 �_� C <br /> O GENERATOR r: USED OIL CERTIFICATION I• U I <br /> ' . m 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.O.T. standards. All relevant information regarding known or <br /> 1 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 /> i:• 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 I _ <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 /> TRANSPORTER <br /> LU <br /> F- CleanTech Environmental, Inc. 14- Pcc <br /> a 2581 S.Sunland Avenue PRIN FULL NAME <br /> Z Fresno, CA 93725 X <br /> EPA ID #:CAL000368136 DRI11 R` SIGNATURE <br /> TANKER# ! D T 1 1 <br /> RECEIVING FACILITY <br /> w i <br /> L The checked box is the designated recycling facility. <br /> 'g w <br /> W P CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID #: CAL000330453 <br /> U< 0 w CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID #: NVR00009005 <br /> a ¢ CI Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 0 <br /> is .. - . <br />