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SERVICE WORK I <br /> CleanTech ORDER <br /> �== Environmental MC. 31316 <br /> 2581 S. Sunland Avenue• Fresno, CA 93725 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.COM <br /> WASTE RECYCLING RECEIPT-BULK FLUIDS <br /> -l: Name Customer Purchase Order# <br /> Address t Sales Representative 1 <br /> City State Zip I I Phone# <br /> EPA ID# . v J f � G Ck#/COD <br /> Manifest# Used Oil / Manifest# Non Haz Wastewater <br /> Manifest#Used Antifreeze Y v <br /> SHIPPING INFORMATION r <br /> cc PART# <br /> U.S. DOT SHIPPING DESCRIPTION CITY. UOM INT PRICE SUB-TOTAL <br /> . . 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 GAL (.C f <br /> CZ 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL } <br />"1- 10043000 NON-HAZARDOUS WASTEWATER GAL I <br /> W Man.Fee MANIFEST DOCUMENT FEE <br /> EA. <br /> w <br /> CIL <br /> o <br /> r c) GENERATOR USED OIL CERTIFICATION <br /> 1 <br /> m USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used ail 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 /> 1 ' suspect hazards associated with this waste have been disclosed. I certify that the waste minimization Statement identified in 40 CFR 26227 li(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 /> 1 <br /> TYPE OR PRINT FULL NAME GENERATOR SIGNATURE D E Z / <br /> I hereby certify that 1 have read and have the authority to bind the above listed generator to the terms found on the front and the back of i <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 1D#is active. This document i <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. <br /> 1 declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> ILU <br /> CleanTech Environmental,Inc. ,� ,f P 4 <br /> _ A 2581 S. Sunland Avenue PRIN F LL NAMET1T� <br /> In z Fresno, CA 93725 X , <br /> EPA ID#:CAL000368136 D 19 R SIGNATURE <br /> TANKER# <br /> W RECEIVING FACILITY ' <br /> w <br /> } The checked box is the designated recycling facility. <br /> w Ch�CleanTech Environmental,Inc.-5820 Martin Road, Irwindale <br /> , CA 91706 EPA ID#:CAL000330453 <br /> w w CleanTech Environmental,Inc.-4910 Donovan Way, Ste.A, N Las Vegas, NV 9801 EPA ID#: NVR0000900 <br /> a ¢ ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N. Las Vegas,NV 92126 �A <br /> 50 <br />