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1 ,. <br /> Corporate Office SERVICE WORK <br /> Tech 5820 Martin Road • Irwindale, CA 91706 <br /> CleanORDER <br /> Phone: 1-800-531-9683 473573 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark ® Sacramento ❑ San Diego <br /> Name "'ifr ' r Customer Purchase Order# <br /> .7.CP l ft_ r � � E' <br /> Address t�� X:X Sales Representative <br /> City State Zip ��I �� C �r t, (� Phone# <br /> EPA ID# F /� Ck#/COD <br /> `"1� e f <br /> Manifest# Used Oil � o{� 1, PYA,� Manifest# Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION• <br /> cc PART# U.S.DOT SHIPPING DESCRIPTION CITY UOM I INTI PRICE SUB-TOTAL <br /> O <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> IM e <br /> Ill <br /> J 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 Z;0 <br /> ; GAL <br /> L7 <br /> >_ 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> ca <br /> O Man.Fee MANIFEST DOCUMENT FEE EA. Z cA5 <br /> W <br /> 0GENERATOR USED OIL CERTIFICATION <br /> U ` <br /> UI 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 /> 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 /> c K y <br /> TYPE OR PRINT FULL NAME GENERATOR 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 for the generatorwaste 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 /> Lu <br /> CleanTech Environmental,Inc. PRINT <br /> FU1�t j E <br /> 2 PRINT FUL•L'NAME <br /> 0 5820 Martin Road r z, <br /> y Irwindale, CA 91706 <br /> Z EPA ID#:CAR000330019 RIVER'S SIGNATURE <br /> TANKER# f. DATE <br /> Lu t7 RECEIVING FACILITY <br /> r KT e checked box is the designated recycling facility. <br /> Ly CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> 0 a ❑ CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N.Las Vegas,NV 89801 EPA ID#:NVR000090050 <br /> LU IL ¢ a ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037 <br />