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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> 1.Generator ID Number Form Approved.OMB N0.2050 0039 <br /> UNIFORM HAZARDOUS 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST �� �� t-50c fi� 017 4 8 <br /> 5. 3 5 8 6 JJ K <br /> Generato s Name and Mailing Add ass IM Ysncbt, (f ddferent than mad ng add ass) <br /> Generator's Phone: "", 0b <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CLEANTECH EM-1RONMENTAL INC CALO00368136 <br /> C 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> e. esgnate aa11ryeine and*-bfle;PZM&dreSS HERITAGE ENVIRONMENTAL SVC LLC U.S.EPA ID Number <br /> 5122 E.STOREY RD 4=DB 1705402 <br /> COOUDGE,AZ 8228 USA <br /> 520-723-4167 <br /> Factillys Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(If arty)) No. I'. Ouanbly . WI-Nd. 13.Waste Codes <br /> 1. RQ,UWASTE <br /> FLAMMABLE,rr.os:, 33 1 <br /> LUBRICANTS),(0001),ERG9126 <br /> u r. V <br /> z 2 <br /> UJ �•.ti <br /> 4. <br /> i <br /> 14.Special Handlingy Instructions and Additional intormo <br /> 981) ROFILn* / "� USE GLOVES AND GOGGLES tRUCK <br /> (AEROSOLS) <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT: INFOTRAC 800-535-5053 <br /> 15, GENERATOR'SfOFFEROR'S CERMCATION:I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are In all respects in proper candition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached OAAclmowledgmenl cf Consent- <br /> I certify that the waste minimization statement Identified in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(ifl am a small cluartlity generator is We. <br /> Generaton'sfOHeroes Printed/ryped me Signature Month Day Year <br /> '? <br /> :,j 16.Inlernalional Shipments L <br /> ❑Import to U.S. ❑Export from U.S. Pod of /exit: <br /> Transponersignature(for exports only): Dale I <br /> U- 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Prinledfryped Nam Signa a Mo th rDay Year <br /> ap,j 10— (A L <br /> l J <br /> QTransp ed/ryp Nam Signature Month Day Year <br /> u <br /> 18.Disaepancy <br /> 18a Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection <br /> ❑FtihBejecbon <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.FPA 10 Number <br /> J <br /> V <br /> r¢i FacRys Phone: <br /> W 18c Signature otAllemate Facility(or Generator) Month Day Year <br /> f- <br /> Q <br /> Z ' <br /> 19.Hazardous Waste Report Management Method Codes(Le,codes for hazardous waste treatment,d#osa(and recycling systems) <br /> LLI� 1. <br /> 4 141 <br /> 20,Designated Facility Omer or Operator.Certification of receipt of hazardous malerials covered by the manifest except as noted In Item ilia <br /> Prind, yped Name S'naWr Month Day Year <br /> r- '2 1 -des � l/ <br /> EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br />