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- 1 <br /> Corporate Office SERVICE WORK �r <br /> Clean Tech 5620 Martin Road• Irwindale, CA 91705 ORDER <br /> Phone: 1-800-531-9683 <br /> www.clea ntechenvcom <br /> WASTE RECYCLING RECEIPT - BULK FLUIDS � <br /> SALES OFFICE: LJFresno 0 Irwindale LlNewark 0 Sacramento I] San Dlego 104 <br /> Name t <br /> f Customer Purchase Order# <br /> r Address Sales Representative <br /> City State Zip f Phone# <br /> EPA IO# `" 5 ..� _ Ck#/COD <br /> fS# Manifest#Used oil ti Manifest#Non Haz Wastewater <br /> Manifest#Used Antifreeze <br /> • SHIPPING INFORMATION fill <br /> PART# U.S.COT SHIPPING DESCRIPTION OTY.IUOM INT PRICE SUB-TOTAL <br /> Ir <br /> 1011221M USED CNL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE coOE 221 <br /> GAL <br /> ui <br /> Z f 001&iM USED ANTI-FREEZE r4ON-RCRA HAZARDOUS WASTE UDUfD,CA WASTE CODE 135 <br /> i 0 GALL <br /> >- 1OD43000 NON-HAZARDOUS WASTEWATER <br /> GAL <br /> LU <br /> uJ Man,Fee MANIFEST DOCUMENT FEE <br /> � E11 � <br /> LU <br /> ,w J <br /> a <br /> UGENERATOR USED OIL CERTIFICATZoN <br /> m USED OIL CERTIFICATION:Any used ad that the Transporter receives from the generator will be transported to a certified used oil recycling <br /> O facility that is lawfully operating in accordance w+th 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 DDT shipping name and are classified, <br /> marked,labeled and are in all aspects in proper condition for transport by D-D.T.standards.All relevant information regarding known or <br /> *;• suspect hazards associated with this waste have been disclosed-1 certify that the waste m1nimiza60n statement identified in 40 CFR 26227 <br /> (a) (it I am a large quantdy generator) or (d) (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 /> 77rPE OFt PRINT FULL FLAME GERERATDR SfGNATIJRE r ~ 7 <br /> DATE <br /> �` t ] !hereby eertify that I have read and have the authority to bind the aboue Nsted generator to the terms found on the front and the back of <br /> Shis faun. f hereby certify this.and all attached documents contain true and accurate descnptions of the waste including that the waste is <br /> egregaled and not camingled with other waste streams.As the Generator,t acknowledge that our site EPA ID#is active and C1eanTech to <br /> sign as agent on the generator waste pro5le worksheet for this wastesireamis]designated for the Clea 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 penally of perjury that rhe foregoing is true and correct. <br /> TRANSPORTER <br /> uJ <br /> i a: Clean Tech Environmental,Inc. <br /> a 5820 Martin Road I <br /> j z Irwindale, CA 91706 <br /> r 1 + EPA ID# CAFi00033p019 t] Id's sIGNATURE <br /> ;1 cc <br /> NK <br /> ER <br /> DATE <br /> Lu o RECEIVING FACILE y <br /> y The checked tMx is the designated recycling faCifity. <br /> 7� i cc ur cy J CleanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 917176 EPA Ip :CAtr00033D453 <br /> • a J Southwest t P ocessamental,' <br /> s t 41217 4910 <br /> Boulvan Way,ard. Ste. <br /> 91508 EPA lD as. NV 9801 EPA ID#,NVRDOgOgp050 <br /> '� � 921 fi41"s037 <br /> t- <br /> � cc <br /> N'r•�i TANKER R GATE <br /> RECEIVING FACILM <br /> W Z The checked bw is the designated recycling iacnLty. <br /> W CleanTech Environmental,Inc.-5826 Martin Road,trwindate CA 91706 EPA 44 ll'CAL <br /> 0�330453 <br /> cc cad CleanTech Environmental.Inc.-4914 Donavan Way,Ste,A,N,Las'Vs,I$1 B93Q1 E4 3 #:NVROW094[15t] <br /> UJ w L6 ❑ Southwest Processors-4120 Bandini Boulvard,Vernon,CA 91509 £PAID#:GAL921 G4 7 <br /> i <br />