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SERVICE WORD <br /> ch � ORDER <br /> � CieanTe . <br /> Environmental Inc. 39-$92 <br /> 2581 S. Sunland Avenue• Fresno, CA 93725 <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com ' <br /> : . WASTE RECYCLING RECEIPT- <br /> BULK FLUIDS: Name I ��•._*;•• I;:,v�i Ssr� c I:r� R: at customer Purchase Order# <br /> Sales Representative <br /> Address I�.f`_`� ►_? li:t='1�,t, td o <br /> R City State Zip [max xltr4t Phone# <br /> l_- <br /> :r _ EPA ID# ,. •. ., , Ck#JCOD <br /> !`.f��It,,3rjhnl' <br /> } Manifest# Used Oil -)3(go/L1 -59 L ut"C, Manifest#Non Haz Wastewater E <br /> E_ Manifest#Used Antifreeze <br /> SHIPPING INFORMATION f <br /> PART# U.S.DDT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB-TOTAL <br />_} � : � 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 22t 3Z GAL <br /> { <br /> w10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> 14043040 NON-HAZARDOU5INASTEvVATER <br /> GAL <br /> 4 In Man.Fee MANIFEST DOCUMENT FEE EA. C <br /> LU <br /> UJ <br /> 7G5 ; <br /> p GENERATOR USED OIL CERTIFICATION f <br /> m USED OIL CERTIFICATION:Any used oil 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, I <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 /> w y non-conforming will be subject to additional charges. f <br /> r ; TYPE OR PRINT RILL NAME GENERATOR SIGNATURE GATE <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 <br /> Ibis 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 cumingied 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. <br /> I I declare under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> W ()� �-� fl - �- <br /> F— CleanTech Environmental,Inc. <br /> ,• � Pf9fFIT FUEL NAME <br /> a 2581 S. Sunland Avenue <br /> 1 _ rn Fresno,CA 93725 x <br /> aEPA ID#:CAL000368136 iDRIVER'�SIGNATURE - <br /> TANKER# OAT£ <br /> RECEIVING FACILITY <br /> UJ <br /> r The checked box is the designated recycling facility. I <br /> w 7-CleanTech Environmental,Inc.-5820 Martin Road, Irwindale,CA 91706 EPA ID#:CAL000330453 <br /> IX w w d CleanTech Environmental,Inc.-4910 Donovan Way,Ste.A, N.Las Vegas, NV 89801 EPA ID#:NVR000090050 <br /> a ❑ Industial Environmental Services- 13350 Grand Valley Parkway, N.Las Vegas, NV 92126 <br /> 97 - - I <br />