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Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road • Irwindale, CA 91706 ORDER <br /> Phone: 1-800-531-9683 483833 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale O`Newark ❑ Sacramento ❑ San Diego <br /> Name �- Customer Purchase Order# <br /> Address 7 7 `��^ o ,/ Sales Representative <br /> p' Y <br /> City State Zip y� rA y 7 ciPhone# <br /> EPA ID# Ck#/COD <br /> i1 G? <br /> Manifest# Used Oil V U r Manifest#Non Haz Wastewater <br /> Manifest# Used Antifreeze —7rJ/Isyo/%/r <br /> SHIPPING INFORMATION <br /> It O PART# U.S.DOT SHIPPING DESCRIPTION CITY. UOM INT PRICE SUB-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> W <br /> IrZ 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 ('JI GAL <br /> f7 wv .( <br /> >_ 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M <br /> W Man.Fee MANIFEST DOCUMENT FEE ' EA,UJ <br /> �y <br /> 7q . <br /> a <br /> O GENERATOR USED OIL CERTIFICATION <br /> U <br /> Lu USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> facility that is lawfully operating in accordance with 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 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 besubjectto additional charges. y� <br /> TYPE'OR PRINT-FULL NAME GENERATOh-SIGNATURE DATE ` <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 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 forthe generator waste stream profile worksheet of these waste streams.I declare <br /> under the penalty of perjury that the foregoing is true and correct. <br /> cc TRANSPORTER <br /> LU <br /> CleanTech Environmental,Inc. l)n • • Ar G <br /> PRINT FULL NAME <br /> O 5820 Martin Road <br /> ZIrwindale, CA 91706 X <br /> EPA ID #: CAR000330019 DRIVER'S SIGNATURE <br /> TANKER# r? DATE <br /> ccs RECEIVING FACILITY <br /> w <br /> Z r The checked box is the designated recycling facility. <br /> w _ 13 CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> w m LL O CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas, NV 89801 EPA ID#:NVR000090050 <br /> a <br /> 0 Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037 <br />