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- SERVICE WORK YORK <br /> 1 ORDER <br /> Carparate office <br /> + � � 5820 Martin Road•Irwindale,CA 91706 73545 <br /> 3545 7 <br /> fY�� <br /> + ' J Phono: 1-800-531-9683 <br /> www.r—learttectionv.com <br /> � i <br /> F: WASTE RECYCLING RECEIPT k B�S� FLUID <br /> ❑ San Diego �� <br /> I't <br /> to <br /> SALES DFFIGi`: U Fresno U lrwinclale ❑ Idewar <br /> Customer Purchase Order# <br /> f� <br /> Name J Sales Representative <br /> i r <br /> ■ Address phone# 4 <br /> City State Zip Ck#1 GOD <br /> EPA ID# <br /> , — Manifest It Non Hoz Wastewater <br /> Manitest#Used Oil <br /> Manifest#Used Antifreeze '. <br /> SHIPPING INFDRMATiON QTY. 1}QM IN <br /> PRICE SUS-TOTAL L <br /> � PART# U.S.I]GT SHIPPING DESCRIPTI�� GAL <br /> d 74422104 USED OIL NON RCRA HAZARDOUBWASTE <br /> LIQUID.CA GORE 221 <br /> i CAL <br /> ua 10413500 USED ANTI-FREEZE NON-RCRA HATARD6U5 WASTE LIQUID,CAWASTE CODE 1"� <br /> Z GAL <br /> CW'3 <br /> + 14p43000 NOK-HAZARDOUS WASTEWATER _ I EA. ' <br /> O Man.Fee MANIFEST DOCUMENT FEE <br /> W <br /> J 0. Q <br /> GENERATOR USED QIL CERTIFICATION { <br /> c� 1 <br /> H$ p OIL CERTIFICATION:lratng n accordance w th a ha hazardous waste faclidie Perm t ssuled pursual be ntrtn�he Fedeto a rlallAcL t hered used oehy declaril e <br /> LU facility that rs proper DOT shipping name and are classified,packaged, <br /> a that the contents of this consignment are fully and accurately descn+ ed above by the p vp <br /> marked, labeled and ari <br /> assoc ta in all ed with this XnOwn Of <br /> cwaste haperbeendition for dis disclosed transportl certfy that the wastedmin m iation statement identified in r 410 GFR 26727 <br /> suspect hoz enerator or (b) (if I am a small quantity generator) us true.Waste materials which are discovered to be <br /> {a]tit f am a large quantity 9 <br /> non-conforming will be sublect to additional charges. <br /> X DATE <br /> GENERATOR SIGNATURE 4 <br /> TYPE OR PRINT FULL NAME ii <br /> " I here I hte ehatcenal ethis�and all attached documents Icanta'rn t4ue anldta�cgueate descriipt to Ons of thew stelincludingtthatt the waste�s <br /> ' I{ segregated and not eomingfed with other waste streams.As the Generator,l acknowledge that our site EPA lD N is active and Cleanis k 0chser to <br /> sign as agedt an the generator waste profile wsrkdse5�linns a d Constituenls found above are unchanged ped for the CleanTech r the Facility Generator Waste <br /> `- as a wr;tten veriticatian that the waste stream ) <br /> Profile Worksheet and also as the annual written veriticati9n#or <br /> the generator waste Stream prolil8 worksheet of these waste streams.l declare <br /> . under the penalty of perjury that the laregoing iS true and correct- . <br /> TIRANSPORTER <br /> a Clea nTech Environmental,Inc. <br /> PR NT FUL/HAM <br /> p 5520 Martin Road <br /> 06 <br /> Irwindale,CA 91706 x NATURE <br /> EPA 11)#,.CAR400330019 D R'S StG 1 <br /> TANKER II HATE . <br /> RECEIVING FACILM <br /> W The checked box is the designated recycling tacilily. <br /> -p C1eanTech Environmental,Inc.-5820 Martin Road,IrwindaleCA V06 EPA ID#;CALOD03313453 <br /> LU LU w p Southwest P oce sorsCleanTech a al4120 B ndi0 Boutvard <br /> Vel , <br /> LU <br /> A, Las Vegas' V$gal6gi21EPA <br /> fl37#.NVFtQa449045Q <br /> CA 91508 EPA ID# G <br />