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Corporate Office SERVICE WORK <br /> CleanTeCh 5820 Martin Road - Irwindale, CA 91706 ORDER <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com 459782 <br /> WASTE RECYCLING RECEIPT - BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark 'E]-Sacramento ❑ San Diego <br /> i <br /> Name ��;.;,. ;,.; �,s;. �. Customer Purchase Order # <br /> Address t i:.. , ,r Sales Representative ; <br /> City State Zip r-_, t;: .r.� Phone # <br /> EPA ID # Ck#/COD <br /> Manifest # Used Oil �L Manifest # Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION <br /> ac PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> O <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 \ GAL <br /> cc <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> W <br /> 0 <br /> y. 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> IM <br /> W Man.Fee MANIFEST DOCUMENT FEE I EA. 7 �J <br /> 7 <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 <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 /> O that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> H <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 <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 /> X <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 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 /> under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> � I / <br /> CleanTech Environmental, Inc. <br /> D: PRINT FULL NAME / <br /> O 5820 Martin Road / <br /> (n Irwindale, CA 91706 X / �y <br /> Z EPA ID #: CAR000330019 DIVER'S SIGNATURE <br /> ilLl � ZZ- <br /> TANKER# DATE <br /> o RECEIVING FACILITY <br /> W <br /> The checked box is the designated recycling facility. <br /> 'M W ' 121�CleanTech Environmental, Inc.- 5820 Martin Road, Irwindale, CA 91706 EPA ID #: CAL000330453 <br /> CC <br /> w LL ❑CleanTech Environmental, Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID #: NVR000090050 <br /> a o= 13 Southwest Processors - 4120 Bandini Boulvard, Vernon, CA 91508 EPA ID #:CAL921646037 <br />