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L. <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ®0-0t0ky- � (�j� 017029623 JJ K <br /> 5.Generator's Name and Mailing AddWs 1 X_�{en ra or'sOySilrtAddress(if different than mailing address) <br /> It, <br /> tors Phone: 0 `v' <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> CLEANTECH E"ARONMENTAL INC. CR.L000368136 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8. esignaed acilil Name and Site Address U.S.EPA ID Number <br /> HERITAGE BPARONNIENTAL SERVCES LLC <br /> a�nnncu+7 ,rn <br /> 284 EAST STOREY ROAD <br /> V +v�`o <br /> COOLIDGE,AZ 85128 USA <br /> Facility's Phone: `5'20-72'-416? <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 any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> X 1• RQ,UN 1950,WASTE AEROSOLS,FL4MMAH1 E,n.o.e.,2.1 (PAINT DM P D001 331 <br /> oLUBRICANTS),(D001)ERr;#126 � � — <br /> `td <br /> z 2. <br /> w <br /> 3, <br /> 4. <br /> 14.Special Handling Instruclions and Add iI')n I I ormation <br /> 9I91) PROFILE# - I USE GLOVES AND GOGGLES TRUCK <br /> (AEROSOLS) <br /> CALLER MUST IDENTIFY CLEANTECH EVAR.ONMENTAL.AS REGISTRANT: INFOTRAC 800-535-5053 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully 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 condition for transport according to applicable international and national govemmenlal 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or()(if I am a small quantity generator)Is true. <br /> Generalors/Offeror's Pdnled/Typed Namew w�n --/"f� Signature on Day Year <br /> .--r16.Intemational Shipments rJ�`�' <br /> r- ❑Import to U.S. Export from U.S. P of entrylexit: <br /> Transporter s:gnalure(for exports only). Da lean ng U.S.: <br /> 12f 17.TranspoderAcknowledgmant of Receipt of Materials <br /> u.r <br /> Transporter 1 Prinled ped Name Signatur Mont Day Year <br /> O <br /> i <br /> CTransporter 2 Pnnted[Ty7ed Name Sig natu a Month Day Year <br /> IOU <br /> a' <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanlity, ❑Type ❑Residue ❑Partlal Refection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> uQ FacilihfsPhone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a1 <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Eli <br /> E i <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a <br /> P' ped NameSig re AMnth Day ear <br /> e- YXr ��Lr J2=taz:::2 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />