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41 <br /> Corporate Office SERVICE WORK <br /> CleanTe <br /> 5820 Martin Road• Irwindale, CA 91706 ORDER <br /> ch <br /> Phone: 1-800-531-8683 456337 <br /> www.cleantechenv.com <br /> D <br /> WASTE RECYCLING RECEIPT • BULK FLUIDS <br /> L3 +� <br /> �111 <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark Sacramento ❑ San Diego <br /> Name C r Customer Purchase Order# <br /> DAddress f 7 f r Sales Representative <br /> ' City State Zip r �✓ Phone # <br /> EPA iD-# / f J 4 Ck#1 COD <br /> Manifest# IYed Oil Manifest#Non Haz Wastewater <br /> Manifest# Used Antifreeze 0-? <br /> i ! HI00I4G INFORMATION <br /> oC PART# U.S.DOT SHIPPING DESCRIPTION OTY- UOM INT PRICE SUB-TOTAL <br /> a p <br /> l '<-' 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 <br /> GAL <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> Lu <br /> -Ca GAL <br /> } 10043000 NON-HAZARDOUS WASTEWATER <br /> m <br /> j � Man.Fee MANIFEST DOCUMENT FEE EA L r 5 -�7 <br /> ! I L-i 5 <br /> i p GENERATOR USED OIL CERTIFICATION <br /> v <br /> to USED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used ail recycling <br /> k M facility that is lawfully Operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act. I hereby declare <br /> I that the contents of this consignment are fully and accurately described above by the proper DbT shipping name and are classified,packaged. <br /> 1 ~ marked, labeled and are in all aspects in proper condition for transport by P.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 44 CFR 26227 <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 /> 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 <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 and CleanTech to <br /> sign as agent on the generator waste profile worksheet for this wastestream(s)designated for the CleanTedh facility.This document serves <br /> as a written verification that the waste stream(s)descriptions and constituents found above are unchanged per the Facility Generator Waste <br /> Profile ten verification <br /> and also as the annual written verification for the generator waste stream profile worksheet of these waste streams.I declare <br /> .+ I under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER , <br /> 1 Cr. I <br /> UJI <br /> ;r 1 CleanTech Environmental,Inc. PRINT FULL�N <br /> 0 5820 Martin Road X <br /> { W [rwindale, CA 91706 RIV R' SIG ATUR 01 <br /> E <br /> 4 EPA ID #:CAR000330019 ' Lf ' <br /> } I , <br /> 2,1 <br /> D TE <br /> TANKER# <br /> i RECEIVING FACILITY <br /> ru= <br /> Th hecked box is the designated recycling facility. <br /> CleanTech Enviranmen#al,Inc.-5820 Martin Road,Irwindale, CA 91706 EPA ID#:GAL000330453 <br /> Iean7ech Environmental,inc. 4910 L3onovan Way, Ste.A, N.Las Vegas, NV 83801 EPA lf3#:NVROOOD90050 <br /> ❑ Southwest Processors-4120 Bandini Boulvard,Vernon, CA 91508 EPA Id#:GAL921646037 <br /> - L <br /> �• ;,.,. _xl^' _ Y _ -� _J �• r♦ .-,j ,'F ate•-- ti. f 7 r .I �. .� •}L , -tei` Y .. <br /> '� _K a .% !"F Je'J _� •1 s. .F s <br />