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r <br /> Corporate Office SERVICE WORK <br /> V CleanTech 5820 Marlin Road a Irwindale, CA 91706 ORDER i <br /> ' Phone. 1-800-531-9683 <br /> www.cleantechenv.com 473547 <br /> all WASTE RECYCLING RECEIPT • BULK FLUIDS M <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark ❑Sacramento ❑ Son Diego M <br /> Name Customer Purchase Order# <br /> Address I _. A.- i Sales Representative <br /> City State Zip _- _ _ Phone# <br /> _ n <br /> EPA 1D C Ck#!COD <br /> C Manifest#Used Oil Manifest#Non Haz Wastewater <br /> Manifest#Used Antifreeze' s r 3 <br /> [ SHIPPING INFORMATION <br /> 0 PART M U.S.DOT SKIPPING DESCRIPTION QTY.iUOM INT PRICE SUB-TOTAL <br /> d 10022100 USED CRL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 K GAL / f <br /> cc <br /> LU <br /> Z 1 DG13600 USED ANTI-FREEZE NON-RCRA HAZARDOUSWA5TE LIQUID,CA WASTE CODE 135 GAL <br /> W <br /> } 10043DOO NON-HAZARDOUS WASTEWATER GAL <br /> m i <br /> W Man,Fee MANIFEST DOCUMENT FEE EA.uj <br /> f" <br /> 11 M A 0 GENERATOR USED OIL CERTIFICATION <br /> w USED OIL CERTIFICATION:Any used oil that the transporter receives tram the generator will be transported to a Cerlihed usod ail"cling <br /> m facrlity that rs lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act-I hereby declare <br /> O that the contents of this consignment are fully and accurately described above by the proper DOT shipping name and are classified,packaged, <br /> marked,iatieted and are to all aspects in proper condition for transport by D.0.1 standards.All relevant information regarding known or <br /> suspect hazards associated with this waste have been disclosed.I eertify that the waste minimization statement identified in 40 GFR 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 /> X r � <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE DATE <br /> w -i 1 hereby certify that t have read and have the authority to bind the above Jilted generator to the terms found on the front and the back of pp <br /> IMP this form. I hereby certify This,and all attached documents contain true and accurate descriptions al 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 CleanTeeb fatality-This document serves <br /> as a written verification that the wade 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 generatorwaste stream profile worksheet of these wasiestreams-I declare <br /> under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> cc <br /> LU <br /> � - = <br /> CleanTech Environmental,Inc. 'PRIN L A —, <br /> 0 5820 Martin Road <br /> U) Irwindale.CA 91706 x <br /> i � EPA la If:CAR000330019 M.NATURE <br /> 2_171 <br /> � r <br /> TANKER M / _ DATE <br /> o a RECEIVING FACILITY <br /> CullZ The checked box is the dosrgnated recycling Iacillty- <br /> w cJ—i Ll CteanTech Environmental,Inc.-5820 Martin Road,Irwindale,CA 91706 EPA ID c CALOD0330453 <br /> uj u ❑ CfeanTech Enviraninnontal,Inc.-4910 Donovan Way,Ste.A,N.Las Vegas,NV 99801 EPA ID#;NVROOD090050 <br /> a Ir la Southwest Processors-4120 Bandini Boulvard,Vernon,CA 91508 EPA ID 4:CAL921646037 <br />