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-® Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road • Irwindale, CA 91706 ORDER <br /> Phone: 1-800-531-9683CNESSM 483676 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ,Q-Newark ❑ Sacramento ❑ San Diego <br /> Name , /! r rr ,r / ,CA )r Customer Purchase Order# <br /> Address ; r I Sales Representative <br /> City State Zip , I JA ( 4- Phone # <br /> EPA ID # Ck#/COD <br /> ' <br /> Manifest# Used Oil Manifest#Non Haz Wastewater <br /> Manifest# Used Antifreeze ( 7�������� I /V45 <br /> SHIPPING INFORMATION ; a <br /> o PART# U.S. DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 (,'�� r AL <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE.LIQUID,CA WASTE CODE 135 GAL f <br /> W <br /> 0 <br /> y 10043000 NON-HAZARDOUSWASTEWATER GAL <br /> M <br /> G Man.Fee MANIFEST DOCUMENT FEE EA. <br /> W <br /> W / i <br /> J <br /> n. <br /> vGENERATOR USED OIL CERTIFICATION,:.r c'n <br /> m 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. 1 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 fos 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 minimizatio -statemegqt identified in 40 CFR 26227 <br /> (a) (if I am a large quantity generator) or (b) (if I am a small quantity genera r) us true. Waste mater' Xhich are discovered to be <br /> non-conforming wilt es}bject to additional charges. <br /> TYPE OR PRINT FULL NAME GENERAT9BSIGN7STURE 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 /> TRANSPORTER <br /> r� <br /> x <br /> W 1\ MAQ if )(AliA/, ) <br /> CleanTech Environmental,Inc. PRINT PUCE NAME <br /> a 5820 Martin Road <br /> C Irwindale, CA 91706 X — a <br /> EPA ID#: CAR000330019 DRIVER'S SIGNATURE <br /> TANKER# ` f DATE <br /> LU RECEIVING FACILITY j <br /> Z The hecked box is the designated recycling facility. <br /> w cJ—i - CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> j w w a EI CleanTech Environmental,Inc.-4910 Donovan Way,Ste.A,N.Las Vegas,NV 89801 EPA ID#:NVR000090050 <br /> a x ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037 <br /> ) <br />