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Please print or type.(Form designed for use on elite(12-pitch)typewntera Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS 1.Generator lD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 moa 016698082 JJ K <br /> 5.Generators Name and Ma➢Ing Address ts Site Address(d diferant Ilan mailing address) <br /> °��Z <br /> CA <br /> Generator`s Phone_ <br /> 6.Transporter 1 Company Name <br /> CLEANTECH EN ORONMENTAL US_EPA ID Number <br /> CALL'00-353136 <br /> Z Transporter 2 Company Name U.S.EPA 10 Number <br /> a.Desigrriied Acility Narle-and Site A ess H qGE ENVIRONMEfdTPi SERVICES LLC U.S.FFA ID Number <br /> 284 EAST STOREY ROAD AZD051705402 <br /> COOLIDGE,AZ 85128 USA <br /> 520-724167 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(atducling Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unll <br /> HM andPaddngGmup(ifany)) <br /> No. Type Quantity WWoI. 13 Waste Codas <br /> 1. uS WASTE.SOLKYn.o-e.,y, c3 III,(PRAXE LMA 81 <br /> o SHP:JiNGS, CHROfv11UM1,(EMT,, ERGM71 � -7 � <br /> 0 Li --i I <br /> w <br /> w 2. I i <br /> CD ! ) <br /> 3. r <br /> f <br /> _t._.---- <br /> t i <br /> i <br /> 4. <br /> f 1 <br /> _ ! I <br /> 14.S peclat Handlingg�lnsbuc6ens and Add�fio 0 -1 <br /> 3@1)PROFILE?; L. USE GLOVES AND GOGGLES TRUCK* <br /> (BRAKE SHWNGS) <br /> CALLER A1UST )DEPMFY CLEAhTTECH ENv1RONMENTAL AS REGISTRANT INFOtPA.0 200--S- -SOSB <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents cf this consignment are fully and accurately desaibed above by the propershippng name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition far transport according to app cable inlemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this oonsi nment confame to the terns of the attached EPAAdknowtedgment of Consent <br /> I certify that the waste minimization statement idenbTied in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true, <br /> Generates106ercesPrntedlTypedName Signature Mo Day Year <br /> SvwM 0 ­b oMt vC,vrcZ 1 a.� t <br /> J 16.Intematicnal Shipments <br /> F— ❑Import to U.S. ❑Export from U.S_ Port of entryfexit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w17,TransporterAcknawledgmentolRecelptofMaterials <br /> � Transporterl Prnle ped Name Sir Month Day +Year <br /> to lr t <br /> Z Transporter 2 Printed/Typed Name S gnaraa Month Day Year <br /> r <br /> 18.Disaapancy <br /> 18a.Discrepancy Indication Space ❑ Quantlty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.A tamate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> F.Aity's Ph.: <br /> w 18c Signature of Alternate Facility(or Genera(or) Month Day Year <br /> Z <br /> 2 19.Hazardous Waste Report Management Method Codes Ga.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ <br /> p 1 '�� Z 3. 4- <br /> 20.Designated Facility Owner or Operator.Codification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Printed/Typed Name Si Month Day Year <br /> cc i� ores 3 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACIUTYTO DESTINATION STATE OF REQUIRED) <br />