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-- r — - .. 4 .- s a f .- _ — .. .- .. <br /> I Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road • Irwindale, CA 91706 a ORDER <br /> Phone: 1-800-531-9683 3 5 <br /> ' www.cleantechenv.com v <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: tl Fresno ❑ Irwindale ❑ Newark ❑ Sacramento ❑ San Diego <br /> Name �` r I ��,0 ClJn r r0 Customer Purchase Order# <br /> Address 1 Cr ^ r n N Sales Representative <br /> City State Zip �� Phone # <br /> EPA ID # 1 Ck#/COD <br /> Manifest# Used Oil r a A rr Manifest# Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> -` SHIPPING INFORMATION <br /> M PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INTI PRICE I SUB-TOTAL <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 Jy GAL <br /> W <br /> W 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUSWASTE LIQUID,CA WASTE CODE 135 GAL <br /> y 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> M <br /> In i <br /> W Man.Fee MANIFEST DOCUMENT FEE I EA. y$ <br /> WCL <br /> 4 <br /> •�� y <br /> o e GENERATOR USED OIL CERTIFICATION <br /> U <br /> WU 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. 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 �`s'' all quantity geneCritor) us true. Waste materials which are discovered to be <br /> non-conforming will be subject to additional charges.(tt U t e <br /> TYOE OR PRINT FULL NAME{ - GENF,ggTOR 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 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 /> ". . <br /> Cr TRANSPORTER <br /> UJI <br /> CleanTech Environmental,Inc. 4 <br /> 01 s <br /> PRI PULL NQ <br /> C 5820 Martin Road <br /> W Irwindale, CA 91706 X` <br /> Cr EPA ID #:CAR000330019 DRI 'S SIGNATURE <br /> TANKER# 2 g DATE <br /> UJ RECEIVING FACILITY <br /> The checked box is the designated recycling facility. <br /> w c-—i 4YCleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> W w ! LlCleanTechEnvironmental,Inc.-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 />