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Please print or type, Form designed for use on elite 12• itch) typewriter.) Form Approved. OMB No, 2060.0039 <br /> UNIFORM HAZARDOUS I1. Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4, Man feat Tracking Num or <br /> WASTE MANIFEST 01868 156 JJ K <br /> S. Generator s Name and Mailing Address n mailing address) <br /> OR <br /> Generator's Phone: L t` '�. Jb 2 <br /> AD <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> CLEANTECH ENXARONEMENTAL t;AL0003b`St35 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 6. Designated Facility Name and Site Address U.S. EPA ID Number <br /> CLEANTECH ENVIRONMENTAL OAL0003304 3 <br /> 5820 ivIARTIN RD <br /> iRWINDALE , CA 91706 USA: <br /> Fad1111 Phone: 526-812=7200 <br /> gas _ gb. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10, Containers t1. Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No, Type Quantity WIJVoi. <br /> a 1 . 410alwFer11gsA kJA r= e. ru irs, ? .& =r r � - <br /> '°- ME�hrt}— <br /> 2, <br /> r NON-RGRA HAZOMOUS WASTE SCrLID (my SOLID WASTE/USED DM P a5* <br /> METAL OIL FILTERS) <br /> 3` <br /> IA I <br /> 4. <br /> 14. Speclal Handling Instructions and Additional Information <br /> 482)PROFILE#F USE GLOVES AND GOGGLES TANFCERy "" <br /> (tv1ETAt. FILTERS) Ga�t_'rr APSnaL39NX . <br /> i <br /> CALLER AWST IDENTIFY CLEANTECH EN\11RONIViF_NTALAS REGISTRANT; INFOTRAt; 500.535- 5053 <br /> '15. GENERATOR'51OFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately described above by. proper shipping name, and are dassi fled, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations, If export shipment and em the Primary <br /> Exporter i cerlily that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consents <br /> I certify, that the waste minimization statement Identiped In 40 CFR 262.27(a) (if i am a large quantity generator) o (dl am a small quanjVMjjt, is true. <br /> Generatoraror's Pdnted/Typed Na Stgnatu Month Day Year <br /> 16, InternationalS ipments <br /> r _ im to U.S. ❑ Export 4mU:S P e ' <br /> Transporter signature (fore its only): Date <br />' 17. TamsporterAckngwledgment of Receipt of Materials <br /> f a As <br /> Transporter Printe 0 ad Name S tin re Month Day >; . :Year <br /> O <br /> ransponer . nt pe t a Signatur Month Day Year <br /> �r. <br /> 18. Discrepancy <br /> 188,.Discrepancy Indication Space M quantity ❑ Type ElResidue ❑ Partial Rejection "w6• ❑ Full Rejection <br /> Manifest Reference.Number. <br /> 18b: Aitemale Fadlity (or Generator) U.S. EPA ID Number <br /> J <br /> Facility's Phone: <br /> 18c. Signature ofAltemate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (Ise,, codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 . 2. r 3. 4. <br /> 4 <br /> 20. DistgnatedFadlityOwnarorOperaorcedincaflonofteosiptolh2 rdous materials covered by the manifest except as noted in item 1 <br /> PrInt6dfTyped Name Nor , ' � 1 Signature Month Da <br /> Al Aq <br /> EPA Form 8700.22 (Rev. HS) Previous editions are obsolete. DESIGNATED FACILV TO DESTINATION STATE (IF REQUIRED) <br /> i <br />