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di <br /> SERVICE WORK t <br /> Tech ORDER I, G <br /> Cgea <br /> Environmental Inc. 32335 G <br /> 2581 S. Sunland Avenue• Fresno, CA 93725 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com O <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> I: Customer Purchase Order# <br /> Name i .. , f Qi .r,QEtE : <br /> Address ,?..;;,, g;•..T+;,:t ritt Sales Representative <br /> �• # <br /> City State Zip i of:.'' Cry f,r,,11 Phone <br /> Ck#/COD <br /> y; EPA ID# ':.y1' 1lli!-3e !; <br /> Manifest#Non Haz Wastewater <br /> Manifest# Used Oil Q3,��1y � 5 <br /> Manifest# Used Antifreeze <br /> != SHIPPING INFORMATION <br /> I: SUB-TOTAL <br /> PART# U.S.DOT SHIPPING DESCRIPTION <br /> O O <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CZTEODTE <br /> cc <br /> Z 10013500 USED ANTI-FREEZE NON•RCRA HAZARDOUS WASTE LIQUID,CA W <br /> U, <br /> !. 10043000 NON-HAZARDOUS WASTEWATER <br /> 1' Co 1 <br /> 0 Man.Fee MANIFEST DOCUMENT FEE <br /> LU <br /> I � , <br /> W <br /> I• o GENERATOR USED OIL CERTIFICATION <br /> I: <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 /> :l <br /> l:. <br /> in facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> b; O0 that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> j marked, labeled and are in all aspects in proper condition for transport by D.O.T.standards.All relevant information regarding known or <br /> : I certify that the waste minimization statement identified in 40 CFR 26227 Ulu <br /> suspect hazards associated with this waste have been disclosed. <br /> jlr+' h (a) (if I ant a large quantity generator) or (b) (if I am a small quantity generator) us true. Waste materials which are discovered to be �) <br /> non-conforming will be subject to additional charges. /. <br /> �-,J <br /> x,��L I� DATE 1, 9 <br />{� TYPE OR PRINT FULL NAME <br /> GENERATOR SIGNATURE <br /> I 0 ' :; . <br /> ' I hereby certify that I have read the above listed generator to the terms found on the front and the back of <br /> -and have the authority to bind <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 uncha?tged per the Facility Generator_ <br /> { ' Waste Profile Worksheet and also as the annual wiitten 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 /> p !;r <br /> 7Ar'Ucc � � � <br /> r CleanTech Environmental,Inc. pRIN FU L NAME j <br /> O 2581 S.Sunland Avenue <br /> N Fresno, CA 93725 DRI ER's S�ATUR� <br /> Q EPA ID #:CAL00036�36 �Z�_ <br /> 1 Cr <br /> DATE J f� <br /> ' .!'• TANKER <br /> RECEIVING FACILITY <br /> w The checked box is the designated recycling facility. 30453 <br /> anTech Environmental,Inc. 5820 Martin Road,Irwindale,CA 91706 EPA ID#:CAL0003#:NVR000090050 ! H <br /> �[p Cle Way, Ste.A, N.Las Vegas,NV 89801 EPA ID F� <br /> l 5 a ❑ CleanTech Environmental Inc. 4910 Donovan F,�( <br /> y;;S' a ¢ U_ ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br />