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f 1 �1 �.. , ems• ��r>-.�...-..�..�._.�.-..�.� - �....�.��— � � � �-.��— <br /> SERVICE WORK : <br /> Corporate Office ORDER ' <br /> 5820 Martin Road • Irwindale, CA 91706 = t a <br /> CleanTech phone: 1-800-531-9683 456368 <br /> • Lauc=i www.rleantechenv.COM <br /> WASTE RECYCLING RECEIPT BU sK FLUIDSramento ❑ San Diego <br /> SALES OFFICE: ❑ Fresno ❑ Irwindale Q New <br /> i <br /> Customer Purchase Order# <br /> Name <br /> r Sales Representative <br /> Address <br /> - rl.� _=,� _l � - •; <br /> City State Zip { i', ; ' Phone# <br /> EPA ID# l Ck#1 COD <br /> 1 �� `L( <br /> c Manifest # Non Haz Wastewater <br /> Manifest # Used Oil <br /> Manifest# Used Antifreeze <br /> SHIPPING INFORMATION <br /> pTY. UOM INT PRICE SUB-TOTAL <br /> o PART# U.S.DOT SHIPPING DESCRIPTION <br /> Q i002210D USED OIL NON RCRA HAZARDOUS <br /> WASTE LIQUID,CA WASTE CODE 221 , GAL <br /> w 10013500 USED ANTI-FREEZE NON-RCRA HAZARDOUS WASTE LIQUID,CAWASTE CODE 135 GAL i <br /> i Z <br /> R; 0 <br /> GAL <br /> } 10043000 NON•HAZARDOUSWASTEWATER X . <br /> I to <br /> I EA. <br /> In Man.Fee MANIFEST DOCUMENT FEE <br /> UJI <br /> ul <br /> 0 <br /> GENERATOR USED OIL CERTIFICATION <br /> w USED loll.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, <br /> l marked, labeled and are in all aspects in proper condition for transport by D.O.T.standards.All relevant information regarding known or <br /> j suspect hazards associated with this waste have been disclosed.I certify that the waste minimization statement identified in 40 CFR 26227 <br /> y (a) (it 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 /> f �f1 xlf" <br /> a 1 i 1� tic. DATA: <br /> 4 PE OR PRINT FULL NAME GE ERATDR SIGNATURE <br /> 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 /> certify that I including that the waste is <br /> 1 hereby fY <br /> l this form, l hereby certify this, and all attached documents contain true and accurate descriptions of the waste c g <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 warksheet for this wastestream(s) designated for the CleanTech facility.This document serves <br /> as a written verification that the waste stream(s)descriptions aiid'constituents found above are unchanged par 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 /> CleanTech Environmental,Inc. -PRINT FULL NAME J <br /> 0 5820 Martin Road <br /> (n ICL rwindale, CA 91706 "DR VER'S SIGNATURE <br /> 3 a EPA ID#:CAR000330019 / <br /> TANKER# DATE <br /> ~ i RECEIVING FACILITY <br /> 4 w i7 <br /> The checked box is the designated recycling facility. <br /> CleanTech Environmental,Inc.-5820 Martin Road, Irwindale, CA 9170fi EPA ID#:CAL000330453 <br /> ISte.A N.Las Vegas, NV I398D1 EPA ID#:NVRo00090050 <br /> Cr a �_CleanTech Environmental,Inc.-4910 Donovan Way, , <br /> 3 l a uJ ru_ ❑ Southwest Processors-4120 Bandini Boulvard,Vernon,CA 91508 EPA ID#:CAL921646037 <br /> � r ~.��1/ 'L� ,., ���..• _ _ f ' ,. Y, f ref t xt ,���,f�, � � ``� <br />