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y SERVICE WORK <br /> J I � Cg n ye c �.! ORDER <br /> Environmental Inc. <br /> 2581 S. Sunland Avenue• Fresno, CA 93725 3 a 9 5) 0 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name I n Customer Purchase Order# <br /> - I � <br /> Address Sales Representative ,s <br /> City State Zip 1.orsi Cjk 4rN747. Phone # I <br /> EPA ID # r'.r �' '1'17s+ <br /> Ck # 1 COD <br /> Manifest# Used Oil �{ 1� t Manifest# Non Haz Wastewater 1 <br /> Manifest # Used Antifreeze <br /> SHIPPING INFORMATION I <br /> a PART# U.S.DOT SHIPPING DESCRIPTION flTY. UOM INT PRICE SUB-TOTAL I <br /> 0 <br /> a 1OG22100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL <br /> cc <br /> Z 100135oo USED ANT#-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135LU <br /> GAt <br /> 100430DO NON-HAZARDOUS WASTEWATER GAL <br /> Man.Fee MANIFEST DOCUMENT FEE EA. �- <br /> i <br /> IL <br /> 0 o GENERATOR USED OIL CERTIFICATION <br /> 0 <br /> mUSED OIL CERTIFICATION:Any used ail 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 /> 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 1 <br /> this form. I hereby certify this,and all attached documents contain true and accurate descriptions of the waste including that the waste is f <br /> segregated and not comingled with other waste streams. As the Generator. I acknowledge that our site EPA ID #is active.This document I 4 <br /> serves as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the Facility Generator <br /> Waste Profile Worksheet and also as the annual written verification for the generator waste stream profile warksheet of these waste streams. <br /> I declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER ,, <br /> LU i <br /> CleanTech Environmental,Inc. f 5 <br /> �Rflw;yULNA € � <br /> O 2581 S.Suntand Avenue <br /> Fresno, CA 93725 rX <br /> EPA ID #:CAL000368 3fi D IV€R'S SIGNATURE <br /> 117 <br /> cc <br /> -' TANKER 11 ATE <br /> RECEIVING FACILITY 1 € <br /> Th checked box is the designated recycling facility. <br /> CleanTech Environmental,Inc.- 5820 Martin Road, Irwindale, CA 91706 EPA ID#:CAL000330453 <br /> eC u CleanTech Environmenw,Inc.- 4910 Donovan Way, Ste.A,N.Las Vegas, NV 89801 EPA ID#: NVR000090050 <br /> to U J Y <br /> a a ❑ Industial Environmental Services-13350 Grand Valley Parkway, N.Las Vegas, NV 92126 j <br /> I <br />