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LN <br /> SERVICE WORK <br /> Corporate Office <br /> i 5820 Martin Road • Irwindale, CA 91706 ORDER <br /> CleanTech <br /> Phone: 1-800-531-9683 456337 <br /> www.cleantechenv.com <br /> N f WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark -O Sacramento ❑ San Diego <br /> . I <br /> Name LI Customer Purchase Order# <br /> Address Sales Representative <br /> v <br /> City State Zip // Phone # <br /> EPA ID # Ck#/COD <br /> I - <br /> Manifest# L ed Oil I Manifest# Non Haz Wastewater <br /> Manifest# Used Antifreeze n7 , 1 —7 71 <br /> ,n_ <br /> ' SHIPI'IIfG INFORMATION <br /> CC PART# U.S.DOT SHIPPING DESCRIPTION 0TY. UOM INT PRICE SUB-TOTAL <br /> O <br /> rr i I Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> VJ I cc <br /> W ) <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> ILL! f� <br /> �r 1 O GAL 10043000 NON-HAZARDOUS WASTEWATER <br /> 03 <br /> W <br /> Man.Fee MANIFEST DOCUMENT FEE EA. z <br /> "% I a <br /> Y�/' � p GENERATOR USED OIL CERTIFICATION <br /> I w USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <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 /> O0 that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> I 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 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 /> .�, nonconforming will be subject to additional charges. <br /> rr 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 and CleanTech to <br /> sign as agent on the generator waste profile worksheet for this wastestream(s)designated for the CleanTech facility.This document serves <br /> as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the Facility Generator Waste <br /> Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams.I declare <br /> 47! I under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> i <br /> � CleanTech Environmental, Inc. PRI <br /> T L NA _ <br /> f O 5820 Martin Road x <br /> U)91706 Irwindale, CA RIVER' SIGNATURE <br /> EPA ID #:CAR0003CC3''0019 `�'7 Z <br /> 1 C <br /> _ DTE <br /> TANKER# RECEIVING FACILITY <br /> I o O <br /> W <br /> •. i Z The checked box is the designated recycling facility. <br /> �j W � rCleanrech Environmental,Inc.Inc. 4910 Don5820 tovanin oWay, Ste.A, NCLasVegas1706 ENV 89801 EPA OID3#: NVR000090050 <br /> cc v a CleanTech Environmental, <br /> WIAJ "' ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#.CAL921646037 <br /> /Jj�? <br />