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SERVICE WORK <br /> Corporate Office ORDER <br /> 5820 Martin Road • Irwindale, CA 91706 <br /> CleanTech Phone: 1-800-531-9683 456368 <br /> www.pleantechenv.com ' <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: Ll Fresno ❑ Irwindale Q Newark fOXSacramento ❑ San Diego <br /> I <br /> Customer Purchase Order# <br /> Name } �� 1 , <br /> j r Sales Representative <br /> Address <br /> Phone # <br /> City State Zip <br /> Ck#/COD <br /> EPA ID # <br /> Manifest # Used Oil `��� 1 L r') �/u <br /> Manifest # Non Haz Wastewater <br /> i <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION <br /> i ©TY. '6—OM INT PRICE SUB-TOTAL <br /> cc PART# U.S.DOT SHIPPING DESCRIPTION <br /> I 09LfJ GAL <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> W GAL <br /> ii 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 <br /> 1: J UJ <br /> 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M EA. <br /> 0 Man.Fee MANIFEST DOCUMENT FEE <br /> W <br /> W /L1 <br /> 2 GENERATOR USED OIL CERTIFICATION 1 <br /> o : <br /> U <br /> cyc <br /> W USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported e a certified used oil declare <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 /> I Othat the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> H <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 /> 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 <br /> GENERATOR SIGNATURE DATA <br /> I I <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 /> 1 sign as agent on the generator waste profile worksheet for this wastestream(s) designated for the CleanTech facility.This document serves <br /> I 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 /> CleanTech EnvironmenCr <br /> tal,Inc. PRINT FULL NAME <br /> cc ro 5820 Martin Road <br /> v°•i Irwindale, CA 91706 DRIVER'S SIGNATURE <br /> ! ¢ EPA ID #:CAR000330019 / <br /> l <br /> ~ I DAT <br /> TANKER# <br /> RECEIVING FACILITY <br /> � 00 <br /> li W The checked box is the designated recycling facility. <br /> I -' -CleanTech Environmental,Inc. 5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> Q L) a d CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID#:NVR000090050 <br /> ' I a LL ❑ Southwest Processors-4120 Ci <br /> Boulvard,Vernon,CA 91508 EPA ID#:CAL921646037 <br /> c <br /> 31 <br /> '�� <br />