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Please print ortype: (Form designed for use on elite (12- ch) typewriter. f Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS i . Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4. Mani <br /> fest Tracking /N�umbber Q <br /> WASTE MANIFEST V 18. 8 `t V 9 �+ 9 JJ K <br /> 5. Generators Name and Mailing Address p,� , l OAR" Site Address different an mailing address) <br /> 3o t tj Ob �Z1'vtQ win Au.Q �I) <br /> Gemirator's Phone$ ��q0 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> CLEANTECH ENVIRONEMENTAL vALn00368138 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> CLEANITECH ENVIRONMENTAL CAL0020330453 <br /> 5820 MARTIN RID <br /> IRININDALE , CA 91706 USA <br /> FadfilyssPhonat 828 61 ?-7�Q0 <br /> ga9b, U.S, DOT Deacriptlon (Including Proper Shipping Name, Hazard Class, ID Number, 10, Contalnoni 11 .Total 12, Unit 13, Waste Codas <br /> HM and Packing Group (if any)) No. Type Quanply WtNol. <br /> 1 FON 066110 tASBORSEN DIV, <br /> _ <br /> ti <br /> Mal pit <br /> 2 NUN-FORA HAZARDOUS WASTE SOLID (OIL'Y SCLIID VUASTEiUSED DM � P 352 <br /> METAL OIL FILTERS) <br /> 3. <br /> 4. ' <br /> 14. Special Handiir g Inslruc0ons andAddigonal Information 7r,� <br /> 98I )PROF16ligg 02)PROFiLEA �i, '•€'G'Fn F USE GLOVESAND GOGGLES TANKERI'#'� <br /> .nh'is an TGP, (METAL FILTERS) rCn ngc'hpKSF01Tl <br /> CALLER MUST IDENTIFY CLEANTECH EN\/ RONMENTAL AS REGISTRANT: INFOTRAC 800-535.5053 <br /> i 15. GENERATOR'SIOFFEROR'S:CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name, and are classified, packaged, <br /> marked and labeledlplacarded; and are in ell respects in proper condition 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 EPA Acknowledgment of Conjpnt. <br /> i I certify that the waste. minimization statement identified In 40 CFR 28227(x) (i(I am a large quantity generator) or (b am a small quantUy generator) is true. <br /> GeneratYalQfierors Printedfiyped N Sign Month Day ser <br /> S <br /> ..1 18. Interratlonal Shipments . <br /> 10&0 U.B. ❑ Export from U.8. P a of a All <br /> Issomme Trane rter signature (for exports only); aF ving .5.: <br /> 17. TranspoderAcknawiedgment of Rocelpt of Matedels <br /> ranspo ass I. PdntedfTypedNrhe Sign lure Mang Day Year <br /> MOM J <br /> TransportirMntedrryped Name Sig Month Day Year <br /> h <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space R Quantity ❑ Type ❑ ResidueJ J <br /> ❑ Partial Re action ❑ Full Rejection <br /> Manifest Reference Number. <br /> IBb. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> tQr. Fatuity's Phone'. <br /> W 18a Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> 19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LU <br /> 0 1 2 3 4 <br /> 20, Designated Facility Owner or OperplarCertification of receipt oLkQrqous materials covered by the manifest except as, noted in Item 18a <br /> snote pa Name Signature Mon Da s <br /> E EPA Form 870042 (Rev, 3.05) Prevlouseditlonsate obsolete, DESIGNATED FACILIEW TO DESTINATION STATE (IF REQUIRED) <br /> i <br /> P <br />