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-� Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road -,Irwindale, CA 91706 ORDER <br /> Phone: 1-800-531-9683 �83 J09 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT • BULK FLUID <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark ❑ Sacramento ❑ San Diego <br /> Name �^^T �-M t �.. f Customer Purchase O der# <br /> Address t _ Sales Representative <br /> City State Zipp ^^ A/d G � Phone# <br /> EPA ID# na f Or k Ck#/COD <br /> Manifest# Used Oil Manifest# Non Haz Walstewater <br /> Manifest# Used Antifreeze c/'1., l U 1L /.IAS 1 <br /> SHIPPING INFORMATION , I <br /> M PART# U.S.DOT SHIPPING DESCRIPTION CITY. UOM INTI PRICE I SUB-TOTAL <br /> Q 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 G L <br /> Q <br /> W <br /> W 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 1l) ) GAIL E)- <br /> 0 <br /> y 10043000 NON-HAZARDOUS WASTEWATER G <br /> W AL <br /> in W Man.Fee MANIFEST DOCUMENT FEE I E <br /> r- <br /> W uS <br /> J <br /> IL <br /> 0 GENERATOR USED OIL CERTIFICATION <br /> W USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transportedlto a certified used oil recycling <br /> m facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to toe Federal Act. I hereby declare <br /> that the contents of this consignment are fully and accurately described above by the proper DOT shipping na a and are classified,packaged, <br /> marked, labeled and are in all aspects in proper condition for transport by D.O.T. standards. All relevant i formation regarding known or <br /> suspect hazards associated with this waste have been disclosed. I certify that the waste minimization stater)ent identified in 40 CFR 26227 <br /> (a) (if I am a large quantity generator) or (b) (if I am a sfia11 quantity generator) us true. Waste materi Is which are discovered to be <br /> non-conforming will be subject to additional charges. <br /> �. tlV (� . � x � � <br /> TYPE ORPFIINT FULL-FAME�, GENEfATOR SIGNATUR L.-- DATE ` <br /> I hereby certify that I have read and have the authority to bind the above listed generator to the terms foun 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 wa to including that the waste is <br /> segregated and not comingled with other waste streams.As the Generator, I acknowledge that our site EPA 10#is active and CleanTech to <br /> sign as agent on the generator waste profile worksheet for this wastestream(s)designated for the CleanTechfacility.This document serves <br /> as a written verification that the waste stream (s)descriptions and constituents found above are unchanged't 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 /> x <br /> WI ,iL1"Inu A Al-1—P10 <br /> CleanTech Environmental Inc. <br /> R ' PRINLLNAME' J <br /> 0 5820 Martin Road <br /> ZIrwindale, CA 91706 I Xt <br /> ¢ EPA ID#:CAR000330019 ` DRlver�'S SIGNATURE <br /> ~ TANKER# _a�+ DATE T t/ <br /> RECEIVING FACILITY <br /> tu I- >The checked box is the designated recycling facility. <br /> n w Er-CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL 00330453 <br /> CC <br /> w a L3CleanTechEnvironmental,Inc.-4,910 Donovan Way,Ste.A, N.La's Vegas, NV 89801 EPA ID#:NVR000090050 <br /> CL ¢ ❑ Southwest Processors-4120 Bandinf Bouivard,Vernon, CA 91508'EPA ID#:CAL9216 6037 <br />