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Corporate Office SERVICE WORK <br /> CleanTech 5820 Marltin Road • Irwindale, CA 91706 ORDER <br /> Phone: 1-1800-531-9683 473572 <br /> www.cieantechenv.com <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE. ❑ Frepno ❑ Irwindale ❑ Newark O-Sacramento ❑ San Diego <br /> Name ` Iffzin I y r,uGl I rJGc � Customer Purchase Order# <br /> Address z C n�r^G�y Sales Representative <br /> City State Zip �� �� Cf� I Phone# <br /> EPA ID # � Afooc�� fl �' Ck#/COD <br /> Manifest# Used Oil ' t Manifest#Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> rix SHIPPING INFORMATIOfiI "' �.• <br /> PART# n U.Si`DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br /> 10022700 USED OIL NON RCRA I�IAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> W10013500 USED ANTI-FREEZE N6N-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 t� GAL <br /> 0 I <br /> } 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M I <br /> W Man.Fee MANIFEST DOCUMEN7�FEE EA• �-I� <br /> W <br /> J <br /> o �Z <br /> 0 _ =GENERATOR USED:OIL CERTIFJCATION " <br /> 4 <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 abcordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> f that the contents of this consignmen are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> marked, labeled and are in all aspe is 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 genera or) 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 /> i <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE <br /> I hereby certify that I have read and ave 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 a I attached documents contain true and accurate descriptions of the waste including that the waste is <br /> segregated and not comingled with oher 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 rofile 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 annuIwrittenverification for the generator waste stream profile worksheet ofthese waste streams.Ideclare <br /> under the penalty of perjury that the fo�egoing is true and correct. <br /> §II TRANSPORTLu <br /> CleanTech Environmental,InI% 11n VI" i `v �vf. � ./, ✓� <br /> 0. 5820 Martin Road PRINT FULL <br /> Z Irwindale, CA 91706 <br /> EPA ID#:CAR000-37300192 ��DRI�R's SIGNATURE J �% <br /> TANKER# DATE r <br /> W c� > - -� RECEIVIIUG FACILITX '} =r J <br /> Y The checked box is the—designated recycling facility <br /> w v Q-CleanTech Environmental,l c.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> W W < ❑ CleanTech Environmental,Irc.-4910 Donovan Way,Ste.A,N.Las Vegas,NV 89801 EPA ID#:NVR000090050 <br /> a ¢ ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037 <br />