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i -- Corporate Office a' SERVICE WORK CleanTech 5820 Martin Road • Irwindale, CA 91706 ORDER Phone: 1-800-531-9683 483261 www.cleantechenv.com WASTE RECYCLING RECEIPT • BULK FLUIDS SALES OFFICE: 111 Fresno ❑ Irwindale ❑ Newark ❑ Sacramento ❑ San Diego Name F M V _ – I, rn for (n/A_Iv r Customer Purchase Order# Address 1 ,-)a2j-15,, On Sales Representative City State Zipv� Phone# EPA ID # r__ – � ' Ck#/COD Manifest# Used Oil vv Manifest# Non Haz Wastewater Manifest# Used Antifreeze z SHIPPING INFORMATION 0 PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 a,AV GAL W / LU 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL U >. 10043000 NON-HAZARDOUS WASTEWATER GAL 00 G Man.Fee MANIFEST DOCUMENT FEE EA -y 1{S W I T W a `'GENERATOR USED OIL CERTIFICATION U " In USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare F that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, marked, labeled and are in all aspects in proper condition for transport by D.O.T. standards. All relevant information regarding known or suspect hazards associated with this waste have been disclosed. I certify that the waste minimization statement identified in 40 CFR 26227 (a) (if I am a large quantity generator) or (b) (if I am a small quantity generators s true. Waste materials which are discovered to be non-conforming will be subject to additional charges. t / �t TYPE OR PRINT FULL NAME GENERATOR SIGNATURE 4 DATE 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 this form. I hereby certify this,and all attached documents contain true and accurate descriptions of the waste including that the waste is segregated and not comingled with other waste streams.As the Generator, I acknowledge that our site EPA ID,#is active and CleanTech to sign as agent on the generator waste profile worksheet for this wastestream(s) designated for the CleanTech facility.This document serves as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the Facility Generator Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams.I declare under the penalty of perjury that the foregoing is true and correct. " TRANSPORTERcc LU CleanTech Environmental,Inc. yttA��nn11IT n,,. c 5820 Martin Road PF!71 �NFF'UULLL-NAME \1 t Z Irwindale, CA 91706 X 1 1� < EPA ID#:CAR000330019 DRIVER'S SIGNATURE Im2l/'J, —11� /�G/ '.J� TANKER# DATE " w cs } vv RECEIVING FACILITY l— The'checked box is the designated 'recycling facility. w M 1:�CIeanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 Lu w ua. ❑ CleanTech Environmental,Inc.-4910 Donovan Way,Ste.A,N.Las Vegas,NV 89801 EPA ID#:NVR000090050 CL ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037