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Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road • Irwindale, CA 91706 ORDER <br /> Phone: 1-800-531-9683 483832 <br /> ' www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale pf Newark ❑ Sacramento ❑ San Diego <br /> Name ��N -t 1 Customer Purchase Order# <br /> Address U� F/L'A 1?GL / Sales Representative <br /> City State Zip l�`131P� Phone# <br /> EPA ID# G LrCOO 7ij7 Ck#/COD <br /> Manifest# Used Oil C1 irk, fir^ --2 Manifest# Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION <br /> G PART# U.S. DOT SHIPPING DESCRIPTION QTY. UOMJINTJ PRICE SUB-TOTAL <br /> IM 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 /3-1) GAL 30 <br /> W <br /> rZ 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> 0 <br /> y 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> m <br /> W Man.Fee MANIFEST DOCUMENT FEE / EA (,J5 <br /> w I <br /> l c0i GENERATOR USED OIL CERTIFICATION <br /> Lw 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 a small quantity generator) us true. Waste materials which are discovered to be <br /> non-conforming will be subject to additional charges. <br /> f <br /> x i- Ly :` U / / / 22 <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 forthe 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 /> w <br /> I— CleanTech Environmental Inc. <br /> ' PRINT FULL NAME <br /> a 5820 Martin Road <br /> rn Irwindale, CA 91706 X i/0!1 <br /> ¢ EPA ID #:CAR000330019 OPIVER'S SIGNATURE <br /> ~ /'/ / / /'2:2 <br /> TANKER# DATE <br /> 0 C5 RECEIVING FACILITY <br /> LU Z j The checked box is the designated recycling facility. h <br /> 9 w LJ CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> Ir Lu w, LL b CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A,N.Las Vegas,NV 89801 EPA ID#:NVR000090050 <br /> a O Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA ID#:CAL921646037 <br />