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C§eanyech � <br /> SERVICE WORK ORDER <br /> Environmental Inc. <br /> 2581 S. Sunland Avenue - Fresno, CA 93725 30500 <br /> Phone: 1-800-531-9683 <br /> wwW.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name <br /> y i Customer Purchase Order# I <br /> Address <br /> I Sales Representative <br /> FEPA <br /> te Zip f ! ' ' <br /> Phone # <br /> I I Ck #/COD <br /> Manifest # Used Oil <br /> Ll I Manifest# Non Haz Wastewater i <br /> Manifest # Used Antifreeze r <br /> SHIPPING INFORMATION <br /> 0 PART# U.S. DOT SHIPPING DESCRIPTION <br /> CITY. UOM INT PRICE SUB-TOTAL <br /> cc <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> GAL <br /> ILLI 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID, <br /> (D CA WASTE CODE 135 GAL \ <br /> M 10043000 NON-HAZARDOUS WASTEWATER <br /> GAL <br /> W <br /> Man.Fee MANIFEST DOCUMENT FEE <br /> I EA. <br /> J � I <br /> i <br /> a pp <br /> O GENERATOR USED OIL CERTIFICATION <br /> U ' <br /> w USED OIL CERTIFICATION: Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling I ' <br /> M 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, I <br /> marked, labeled and are in all aspects in proper condition for transport by D.O.T. standards. All relevant information regarding known or i <br /> suspect hazards associated with this waste have been disclosed. I certify that the waste minimization statement identified in 40 CFR 26227 l <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-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 I <br /> serves as a written verification that the waste stream (s)descriptions and constituents found above are unchanged per the Facility Generator r <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. I I <br /> TRANSPORTER l <br /> ac I <br /> CleanTech Environmental Inc. q ^ i,�',! <br /> cc -MINT FUrL NAME- <br /> 0 2581 S. Sunland Avenue / <br /> N Fresno, CA 93725 <br /> Z EPA ID #: CAL000368136 'DR ER'S�IGNATURE <br /> cc <br /> TANKER# L, DATE <br /> c5 <br /> RECEIVING FACILITY <br /> LLJ <br /> J The checked box is the designated recycling facility. <br /> - ,0 CleanTech Environmental,Inc.- 5820 Martin Road, Irwindale, CA 91706 EPA ID #:CAL000330453 <br /> oc U a ❑ CleanTech Environmental,Inc.- 4910 Donovan Way, Ste,A, N.Las Vegas, NV 89801 EPA ID#: NVR000090050 <br /> UJ a- Q LL ❑ Industial Environmental Services - 13350 Grand Valley Parkway, N. Las Vegas, NV 92126 <br /> i � <br />