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�i 11 • ii � <br /> f WORK <br /> SERVIr <br /> CleanTech <br /> Environmental Inc. ' <br /> 2581 S.Sunland Avenue•Fresno, CA 93725 <br /> I Phone: 1-800-531-9683 <br /> I www-cleantechenv.corn <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name n'r�.: r ri• nr rtS��C rvn,iA , <br /> Customer Purchase Order# 1 <br /> k Address ,;� i.;nrr.•rr .en 11 <br /> Safes Representative �. <br /> ' City State zip t <br /> EPA ID# Phone# <br /> -' —�— :- Ck#1 COD <br /> } Manifest 0 Used oil <br /> 01 J � Manifest#Non Haz Wastewater <br /> ■ Manifest# Used Antifreeze <br /> SHIPPING INFORMATION <br /> ppm PART# U-S. DOT SHIPPING DESCRIPTION QTY, UOM INT PRICE SUB-TOTAL <br /> 1 0022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> c. ILLU <br /> , <br /> lys W 100135M USED ANTIFREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 136 GAL i <br /> 10043NO NON-NAIARDOUSWASTEWATER GAL <br /> W Min-Fse MANIFEST DOCUMENT FEE � <br /> F- F.A. <br /> L LU <br /> C, u <br /> GENERATOR USED OIL CERTIFICATION <br /> w 11SED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certitled used oil recycling <br /> 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 CLOT shipping name and are classified,packaged, <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 /> NON suspect hazards associated with this waste have been disclosed. I certify that the waste minimization statement identified in 411 CFR 26227 <br /> (a) (If l am a large quantity generator) or (b) (1f I am a small quantity generator) us true. Waste materials which are discovered to be <br /> IGO non conforming will a subject to additional charges. / <br /> i TYPE OR PAINT FULL NAME GENERATOR SIGNATURE DATE <br /> I hereby certify that I have read and have the authorHy to bind the above listed generator to the terms found on the front and The back of <br /> this farm. 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 0 is active.This document <br /> serves as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the facility Generator <br /> Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams, <br /> f declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> Ir dcl <br /> CieanTech Environmental,Inc. PRINT Fust.NAME -- <br /> 2581 S. Sunland Avenue <br /> Fresno, CA CA 93725 x ` <br /> Q EPA ID d; CALO 0368136 ORrvER'S SIGN-A.URE <br /> TANKER r _ DATE <br /> RECEIVING FACILITY <br /> The checked box Is Rhe designated recycling facility. <br /> leanTeclt Environmental,Inc,-5820 Martin Road, Irwindale,CA 91705 EPA IDM:CALOOMI 453 <br /> Lit <br /> feanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA 1D It:NVR0000940M <br /> dustlal Environmental Servlcas- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br />