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- SERVICE WORK VORK <br /> 1 ORDER <br /> Corporate office <br /> + � � 5820 Martin Road•Irwindale,CA 91706 73545 <br /> 3545 7 <br /> fY�� <br /> + ' J Phono: 1-800-531-9683 <br /> www.r—learttectionv.com <br /> � i <br /> F: WASTE RECYCLING RECEIPT k B�S� $ ��� ❑ San Diego �� <br /> I't <br /> to <br /> SALES DFFIGi`: C1 Fresno ❑ lrwinclale ❑ Idewar <br /> Customer Purchase Order# <br /> f� <br /> Name J Sales Representative <br /> i r <br /> ■ Address phone# 4 <br /> City State Zip Ck#1 GOD <br /> EPA ID# <br /> , — Manifest It Non Haz Wastewater <br /> Manitest#Used Oil <br /> Manifest#Used Antifreeze '. <br /> SHIPPING INFDRMATiON QTY. 1}QM IN <br /> PRICE SUS-TOTAL L <br /> � PART# U.S.I]GT SHIPPING DESCRIPTI�� GAL <br /> d 704221DD USED OIL NON RCRA HAZIIRDOUBWASTE LIQUID.CA GORE 221 <br /> i CAL <br /> ua 1aa13500 USED ANTI-FREEZE NON-RCRA HATARD6U5 WASTE LIQUID,CAWASTE CODE 1"� <br /> Z GAL <br /> CW'3 <br /> + 1Qp43000 NOfy HAZARDOUS WASTEWATER _ I EA. ' <br /> O Man.Fee MANIFEST DOCUMENT FEE <br /> W <br /> J Q <br /> 0. GENERATOR USED QIL CERTIFICATION { <br /> c� 1 <br /> H$ p OIL CERTIFICATION:l ratng n accordance w th a ha hazardous waste faclidie Perm t ssuled pursual be ntrtn�he Fede to a rlallAcL t hered used oehy declaril e <br /> LU facility that rs proper DOT shipping name and are classified,packaged, <br /> a that the contents of this consignment are fully and accurately descn+ ed above by the p vp <br /> marked, labeled and ari <br /> assoc ta in all ad with this XnOwn Of <br /> cwaste haperbeendition for dis disclosed transportl cartfy that the wastedmin m iation statement identified in r 410 GFR 26727 <br /> suspect hazards enerator or (b) (if I am a small quantity generator) us true.Waste materials which are discovered to be <br /> {a]tit f am a large quantity 9 <br /> non-conforming will be sublect to additional charges. <br /> x DATE <br /> GENERATOR SIGNATURE 4 <br /> TYPE OR PRINT FULL NAME ii <br /> " I here I hte ehatcenal ethis�and all attached documents Icanta'rn t4ue anldta�cgueate desc ipt to ons of thew stenncludingtthatt the waste�s <br /> ' I{ segregated and not eomingfed with other waste streams.As the Generator,l acknowledge that our site EPA lD N is active and Cleanis k 0chserves <br /> to <br /> sign as agedt an the generator waste profile wsrkd05�1'ninns a d Constituenls found above are unchanged ped for the CleanTech r the Facility Generator Waste <br /> `- as a wr;tten veriticatian that the waste stream ) <br /> Profile Worksheet and also as the annual written veriticati9n#or <br /> the generator waste Stream prolil8 worksheet of these waste streams.l declare <br /> . under the penalty of perjury that the laregoing iS true and correct- . <br /> TIRANSPORTER <br /> a CleanTech Environmental,Inc. <br /> PR NT FUL/NAM <br /> p 51320 Martin Road <br /> 06 <br /> Irwindale,CA 91706 x NATURE <br /> EPA 11)#,.CAR400330019 o R'S StG 1 <br /> TANKER II HATE . <br /> RECEIVING FACILM <br /> W The checked box is the designated recycling tacilily. <br /> -p C1eanTech Environmental,Inc.-5820 Martin Road,Irwindale CA 9i706 EPA ID#;CALOD03313453 <br /> a LU Li- Southwest P oce sorsCleanTech tal 4t20 B ndi0 Boutvard Vernone A, Las Vegas' V$gal6g121 EPA <br /> fl37#.NVFtQa449045Q <br /> CA 91508 EPA ID# G <br />