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C§eaSERVICE WORK <br /> n Te ch � ORDER <br /> Environmental Inc. <br /> 2581 S. Sunland Avenue - Fresno, CA 93725 30500 <br /> Phone: 1-800-531.9683 q <br /> WWW.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name ; ( <br /> Address <br /> Customer Purchase Order# <br /> � � - .� --- <br /> 1 . . _ Sales Representative <br /> City State'zip <br /> a Phone # <br /> EPA ID - <br /> r . Ck#1 COD <br /> ManifestE# UsEedAntifree <br /> LJ -( S L Manifest# Non Haz Wastewater � <br /> Manifestze Y r <br /> SHIPPING INFORMATION <br /> F! <br /> PART# U.S.DOT SHIPPING DESCRIPTION <br /> tTY. UOM —INT PRICE SUS-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> LLI <br /> GAL <br /> W 10013500 USED ANTI-FREEZE NDN-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL , I <br /> a ] <br /> m <br /> 10043000 NON-HAZARDOUS WASTEWATER <br /> GAL <br /> LU 0 Man.Fee MANIFEST DOCUMENT FEE <br /> CL <br /> 0 � <br /> O TOR USED OIL CERTIFICATION <br /> U GENERA - <br /> uu USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <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 /> OR that the contents of this consignment are fully and accurately described above by the proper DOT 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 /> 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 y 14 '/ r ` I )� J <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE I j <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.This document i <br /> serves as a written verification that the waste stream (s)descriptions and constituents found above are unchanged per the Facility Generator r <br /> Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams. <br /> I declare under the penalty of perjury that the foregoing is true and correct. <br /> I <br /> TRANSPORTER <br /> ac <br /> F CleanTech Environmental, Inc.r RI T L <br /> D 2581 S.Sunland Avenue <br /> U) Fresno, CA 93725 ! / <br /> EPA ID#:CAL000368136 r jA ER`5$GNATURE / <br /> TANKER# DATE C <br /> RECEIVING FACILITY <br /> LU z The checked box is the designated recycling facility. <br /> r0 CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 { <br /> LU w <br /> L3 CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A. N.Las Vegas, NV 89801 EPA II]#:NVR000090050 <br /> a of ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br /> i <br />