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Corporate Office SERVICE WORK <br /> CleanTech 5820 Martin Road • Irwindale, CA 91706 <br /> ORDER <br /> Phone: 1-800-531-9683 <br /> www.cleantechenv.com 459782 <br /> WASTE RECYCLING RECEIPT - BULK FLUIDS <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale ❑ Newark 'J-Sacramento ❑ San Diego <br /> Name ;.s,':•;, r, :;i;,;; . ".'. T ;, Customer Purchase Order# <br /> Address E 1;,..; ti„j Sales Representative v:4; <br /> City State Zip y ;;r;, F- {; .r,t Phone # <br /> EPA ID # Ck#1 COD <br /> Manifest# Used Oil 0_302 Z Manifest # Non Haz Wastewater <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION <br /> cc PART# U.S.DOT SHIPPING DESCRIPTION QTY. UOM INT PRICE SUB TOTAL <br /> D <br /> 10022100 USED OIL NON RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 221 i1 GAL <br /> Z 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CA WASTE CODE 135 GAL <br /> LU <br /> y 10043000 NON-HAZARDOUS WASTEWATER <br /> GAL <br /> m <br /> W Man,Fee MANIFEST DOCUMENT FEE ; EA. <br /> I— <br /> ILI <br /> 7 <br /> a GENERATOR USED OIL CERTIFICATION <br /> c� <br /> mUSED OIL CERTIFICATION:Any used oil that the transporter receives from the generator will be transported to a certified used oil recycling <br /> O facility that is lawfully operating in accordance with a hazardous waste facilities permit issued pursuant to the Federal Act, I hereby declare <br /> p. 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 O.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 <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 CleanTech 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 Worksheet and also as the annual written verification for the generator waste stream profile worksheet of these waste streams.I declare <br /> under the penalty of perjury that the foregoing is true and correct. <br /> TRANSPORTER <br /> w CleanTech Environmental Inc. <br /> I PRINT FU L NAME <br /> O 5820 Martin RoadCL // <br /> Irwindale, CA 91706 x- <br /> 4 EPA ID #: CAR000330019 p IVER'S SIGNATURE <br /> JLI <br /> TANKER# DATE <br /> o O RECEIVING FACILITY <br /> w <br /> z The checked box is the designated recycling facility. <br /> g w v 6(CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 91706 EPA ID #:CAL000330453 <br /> w L< ❑ CleanTech Environmental,Inc.-4910 Donovan Way, Ste,A, N.Las Vegas, NV 89801 EPA ID #:NVR000090050 <br /> a 0 Southwest Processors -4120 Bandini Boulvard,Vernon, CA 91508 EPA ID #:CAL921646037 <br />