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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS• i.Generator ID Number '� Form Approved.OMB No.2050.0039 <br /> 2 Page 1 of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST I� l <br /> 5.Generalo(s Name and Mailing Addl yr l� �a 017 4 8 3 5 8 8 JJK <br /> q CdereM Dian mating address) <br /> Ncvc <br /> Generalo(s Phone: <br /> 6.Transporter 1 Company Name <br /> CLEiMTECH EM/IRONMENTAL INC U.S.EPA ID Number <br /> 7.Transperter2 Company me CAL000368136 <br /> �I U.S.EPA ID Number <br /> 8.Designated aclli an d Ile Address <br /> ERITAGE ENVIRONMENTAL SVC LLC U.S.EPA 10 Number <br /> 5122 E.STOREY RD <br /> '� COOLIDGE,AZ 8228 USA AZD081705402 <br /> Facditys Phone: 520 74167„ <br /> ga 9b.U.S.DOTDesaipfion(mcludingProper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Ccnlainers 11.Total 12.Unit <br /> No. Type Quantity WUyoL 13.Walla Codes <br /> 1" ASTEAEROSOLS,FLAMIv1ABLF,rl2"1,(PAJNT, <br /> p LUE9RICANTS),(DOOij,ERG9126 �� Q P 0001 3311 <br /> rt� <br /> 2. <br /> Uj <br /> ' I <br /> 4. <br /> 14.Spet3elJdalydGn0.lp$ and Addltiona <br /> (AEROSOLS) USE GLOVES AND GOGGLESUC r' <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTALAS REGISTRANT: INFOTRAC 800 535 SOSi <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare That the contents of this consignment are"and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects In proper ccridition for transport aaording to applicable International and national govemmerdat regula8ons.If export shipment and lam the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR26227(a)(if I am a large quantity generator)or jb)(dl am a sma l quantity generator)is true. <br /> Generafo(slOffero(s Printed yped Name Signature <br /> Xame 4; g Month Day Year <br /> �) . <br /> 16.International Shipments <br /> Z ❑Import to U.S. v: Expo t frbm[1 SI Port o1 entryfaxit <br /> Transporter signature(for exports only): <br /> Rte reeling U.S_ <br /> w 17.Transporter Acknowledgment afReceipt of Materials <br /> 0 T a opo to 1 P rated yped Nae S Month Day Year <br /> CIL <br /> rn <br /> Q Transponer 2 Pd edfTyped Nanw Signature <br /> 7,1 Z I r &—If <br /> Month Day r <br /> � t <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space O entity [:]Ty;. ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 16b.Alternate Facility(or Generator) Manifest Reference Number. <br /> U.S.EPA ID Number <br /> J <br /> U <br /> ti Facility's Phone: <br /> Q18cSignature ofMemateFaculty(or Generator) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(.e,codes fou hazardous waste treatment,disposal,and recycling systems) <br /> _ t 1 <br /> S� r <br /> 3 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous mals ao'rgd by the manifest except as noted m Ilemi8a <br /> Printed/Typed Name -.;P <br /> s ; <br /> CIA�c C-1� Month Day Year <br /> EPA Form 8700-22(Rei-3-05) Previous ed6ons are obsolete. DESIGNATED FAMITY•.TO•.DESTINATION STATE(IF REQUIRED) <br />