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—..�■ - u+rlC <br /> 5820 Mart" e <br /> Phone: 1.80 0-$3 Road•frWndale. CA 4i-7r,, <br /> - wwu,..,�. 0 i-Geo•, <br /> Car orate Office SERVICE WORK <br /> C>rQ�l] Prh 5829 Martin Road•Irwindale, CA 91706 ORDER 4; <br /> Phone: 1-800-531-9683 <br /> ►Ww473633 <br /> w.c l ea ntec he m►.c o m <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS Die <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark 4 Sacramento ❑ San Diego <br /> FA <br /> ameCustomer Purchase order# <br /> ddress Sales Representative <br /> nc inn <br /> i City State Zip _ � I Phone# C' _ '+ ti C <br /> EPA ID # _, Ck#I COD <br /> t� Manifest# Used Oil - Manifest#Non Haz Wastewater <br /> Manifest # Used Antifreeze <br /> SHIPPING INFORMATION St1$ <br /> D PART# U.S.DOT SHIPPING DESCRIPTION OTY. UOM INT'PRICE SUB-TOTAL <br /> 14022100 USED OIL NDN RCRA HAZARDOUS WASTE LIQUID.CA WASTE CODE 221 GAL <br /> LU <br /> Z 10013504 USED ANTI-FREEZE NON•RCRA HAZARDOUS WASTE LIQUID,C0.WASTE CODE 135 GAL <br /> W <br /> 0 GAL <br /> 10043000 NON-HAZARDOUSWASTEWATER <br /> C Man.Fee MANIFEST DOCUMENT FEELLI <br /> EA <br /> r <br /> W <br /> J <br /> "e M GENERATOR USED OIL CERTIFICATION iclrn <br /> o Oar <br /> ca <br /> w USED OIL CERTIFICATION:Any used ail that the transporter receives from the generator will be transported to a certified used oil recycling fed <br /> Co facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act.I hereby declare h or <br /> 0 that the Contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged. P27 <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 /> be <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 /> x , <br /> TYPE OR PRINT FULL NAME <br /> 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 e i the front and the back❑f <br /> Lt 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 I 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.l declare <br /> . under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER . <br /> aCfeanTech Environmental,Inc. PRINT FULL NAME <br /> a 5820 Martin Road x - <br /> N Irwindale, CA 91706 DRIVER'S SIGNATURE <br /> aEPA ID #:CAR000330019 <br /> I'_ DATE <br /> TANKER 11 <br /> RECEIVING FACILITY <br /> r� x checked riax is the designated recycling facility- <br /> : CleanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 91asV706 EPAt4V ID#:1 EPA ID#:NV <br /> ❑ CleanTech <br /> Environmental, <br /> oses ors 4120 f3andin0ii BoLi ard,Vernon. CA 91508 Donovan Way, EPA lD#.CAL921fi460D# NVR00009Q050 <br /> UJ <br /> pC [I Southwest <br /> Purnr e6ulva "al,3`te. A N'um OT]W'EPA ID#:CAL000330.453 <br /> - rd'Vernon, ,91gas Vegas,NV89801 EPA ID#:NVR00009 1 <br />