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' SERVICE WORK <br /> �.. : C§eanyech ORDER ' <br /> Fnvironmen#ai Inc. <br /> 2581 S. Suniand Avenue* Fresno, CA 93725 30161 <br /> Q 'Phone: 1-800-531-9683 <br /> www.cleantechenv.com <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> Name ,3: r'r, : Customer Purchase Order# <br /> fl . Address ,.,:: ,, r, Sales Representative <br /> i •r• City State Zip Phone# a <br /> Q EPA ID# ` ... Ck#I COD <br /> � �=1� �?D0� � 111� . <br /> Manifest# used Oil - U i Manifest# Non Haz Wastewater <br /> i <br /> Manifest#Used Antifreeze 3 <br /> SHIPPING INFORMATION i <br /> { O PART i U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUS-TOTAL <br /> Q 100222100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 r GAL <br /> 0= w <br /> W <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL r� <br /> 10043000 NON-HAZARDOUS WASTEWATER GAL <br /> Man.tree MANIFEST DOCUMENT FEE EA. L <br /> LU <br /> Ui <br /> 00i GENERATOR USED OIL CERTIFICATION <br /> 01 <br /> W USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling i1 <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 e <br /> i° (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 /> • i 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 an 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.This document <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 worksheet of these waste streams. j' <br /> declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> 9 � CleanTech Environmental Inc. /�) .�, � <br /> cc ' 'PRINT FALL NAME / r <br /> a 2581 S.Sunland Avenue /J f <br /> W Fresno, CA 93725 X <br /> a EPA ID#:CAL000368136 D(i VER'5 SEGAfATUREf y� F <br /> TANKER# 72_", DATE <br /> RECEIVING FACILITY <br /> The checked box is the designated recycling facility. <br /> uj ,f]CleanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 91706 EPA ID#:CALOOD330453 <br /> V a D CleanTech Environmental,Inc.-4910 Donavan Way,Ste.A,N.Las Vegas,NV 89801 EPA ID#:NVRO00090050 <br /> r•i,�:;.. .� a X r` ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas,NV 92126 ,k�� <br />