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1 J �jj SERVICE WORK <br /> c� Cg e a ,� U l. c U ORDER <br /> Environmental Inc. <br /> 2581 S. Sunland Avenue • Fresno, CA 93725 3 0 g 0 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com W <br /> WASTE RECYCLING RECEIPT- BULK FLUIDS <br /> Name I, t r:z!-i-t Customer Purchase Order# <br /> l <br /> Address ; :• t t.:nri�:� ;;rl Sales Representative <br /> City State Zip t Orli Phone # <br /> EPA ID # :r�q,�t,, •x t,i d a Ck # /COD t <br /> Manifest # Used Oil f' 1� , ✓�, Manifest # Non Haz Wastewater ; 1 <br /> Manifest # Used Antifreeze <br /> SHIPPING INFORMATION <br /> Cr PART # U.S. DOT SHIPPING DESCRIPTION OTY. UOM INT PRICE SUB-TOTAL <br /> O <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 a, GAL <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> W <br /> OGAL <br /> 10043000 NON-HAZARDOUS WASTEWATER <br /> M <br /> 0 Man.Fee MANIFEST DOCUMENT FEE EA. /L <br /> W <br /> W FM <br /> 0 GENERATOR USED OIL CERTIFICATION <br /> o <br /> jW 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 /> 00 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 I <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. ( C <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE t <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 , <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 /> I declare under the penalty of perjury that the foregoing is true and correct. E <br /> TRANSPORTER <br /> Cr <br /> CleanTech Environmental,Inc. <br /> PRINY U L NAME <br /> O 2581 S. Sunland Avenue <br /> ai Fresno, CA 93725 X — <br /> _ Q EPA ID #: CAL000368 36 TATE/IVER'S SIGNATURE <br /> Cr <br /> TANKER# <br /> C) c� <br /> RECEIVING FACILITY <br /> w <br /> Z The checked box is the designated recycling facility. <br /> wZi <br /> -CleanTech Environmental, Inc.- 5820 Martin Road, Irwindale, CA 91706 EPA ID #:CAL000330453 <br /> Cc <br /> w 5 6 CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID #: NVR000090050 f <br /> a CC ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br /> C <br />