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-® Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road • Irwindale, CA 91706 ORDER <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com 483662 <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale 12 ewark ❑ Sacramento ❑ San Diego <br /> NameTr L-\n,71 V--A , f r ,` r �^t�� Customer Purchase Order# <br /> Address ✓� )7 tF( Sales Representative <br /> Cit ✓ L <br /> City State Zip N Phone# <br /> EPA ID#,. f '9! 1 .� Ck#/COD <br /> Manifest# Used Oil Manifest# Non Haz Wastewater <br /> Manifest#Used Antifreeze <br /> SHIPPING INFORMATION <br /> PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INTI PRICE SUB-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 `l GAL o <br /> w <br /> W 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> > 10043000 NON-HAZARDOUS WASTEWATER GAL <br />'j m <br /> W Man.Fee MANIFEST DOCUMENT FEE EA. L- <br /> II W f <br /> J <br /> a <br /> 0 GENERATOR USED OIL CERTIFICATION 1 <br /> ul M USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> O facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> F- 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 fob 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 sm1�1 quantity generator) us true ste materials which are discovered to be <br /> non-conforming will be subjectto additional charges. <br /> n {fi <br /> T jP O T-FULT.NhUE'��V\, 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 gt, <br /> Ir <br /> LU <br /> CleanTech Environmental, Inc. <br /> 0: PRINT FULL NAME <br /> O 5820 Martin Road <br /> coIrwindale, CA 91706 X � ✓ <br /> ¢ EPA ID#:CAR000330019 DRIVER'S SIGNATURE <br /> 7--7 <br /> TANKER# � DATE -' <br /> O RECEIVING FACILITY <br /> W > i_ The choked box is the designated recycling facility. <br /> r E �_ p—CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> w w LL LJ CleanTech Environmental,Inc.-4910 Donovan Way, $te.A, N.Las Vegas,NV 89801 EPA ID#:NVROOD090050 <br /> CL ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037 <br />