Laserfiche WebLink
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 Number2, Page 1 of f3. Emergency Response Phone 4, Manifest Tracking Number, <br /> WASTE MANIFEST �(� l'' {�` c b�T9T 019015431 JJ K <br /> 5. Generator's Name and Mailing Address <br /> t}'-�_ es Site Address (If r !111ng address) <br /> Xs)4nIMMIMAMA <br /> LoiA <br /> E( <br /> Generator's Phone: <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> CLEANTECH ENVIROMENTAL INC. CALOOD388136 <br /> 7. Transporter Company Name U.S. EPA ID Number <br /> 8, Designated Facliily Name and Site Address CLEANTECH ENVIROMENTAL U.S, EPA ID Number 1ROOQ33Q�i53 <br /> 5820 MARTIN RD <br /> IRWINDALE, CA 91705 USA <br /> Faciilt s Phone: 628.812-7200 <br /> ga, gb; U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Cordell ers 11 . Total 12, Unit 13, Waste Codas <br /> HM and Packing Group (if any)) No, Type Quantity WIN011 <br /> ce O 1 0 <br /> W 2. NO*RCRA HAZARDOUS WASTE SOLID (OILY SOLID WASTE(USE DM P 352 <br /> METAL OIL FILTERS) <br /> 3. . NGt=RGRA+ AMOGUS*MSTE-SGLAD#JSEGARSAR8 l09M 962 <br /> 4. <br /> 14. Speaal Handling tnstructions and Additional Information , .� <br /> ,. <br /> 9t3tjPR6FtL-E -- . 02)POFILE#� 17 FfEEtM ---- USE GLOVESANDGOGGLISS 'O�WGW2. � <br /> -(1ei4PEibffE }- (METAL FILTERS) <br /> CALLER MUST IDENTIFY CLEANTECH EWIROMENTAL AS REGISTRANT: INFOTRAQ 800.535.5053 <br /> 16. 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 claseiped, packaged, <br /> marked and labeledlplaoarded, and are in all respects in proper condlUon for transport according to applicable Intematlonaland national governmental regulations. If export shipment and lam the Pdmary <br /> Exporter, I carlily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that t4 rite minimliaUon sietement idenlinad in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (ifl am a small quanlitygenerator) Is We: <br /> Generalor' or's PdntedPtyped Name {�^ gnatureMonth Dayeaear <br /> E \ U.7 <br /> 16, IntemetWO Shipments <br /> i ❑ Import to U,S. ❑ Export from U,S. Port of entrylexlt: <br /> Z Transporter signature (for exports only): Date leaving U,S <br /> Ix 17. TransporterAcknowledgmenlo1Receipt ofMaterials <br /> j Transporter 1 Printedne a/rypad me SigMo h Day of <br /> 0 <br /> an Q a6 Lc:: 16 lk� <br /> Transpoder2 Pdnledrryped Name Signa Month Day Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space F quantity ❑ Type ❑ ResiduePartiatRe action j ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> LL. Facility's Phone: <br /> w 18c. Signature ofAilemate Facility (or Generator) Month Day Year <br /> 4 <br /> S219, Hazardous Waste Report Management Method Codes O,e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> p 1 . 2, 1c) <br /> 3. 4. <br /> 20, Designated Facility Owner or Operator, Cortin Uon of receipt of hazardo maledals covered by the manifest except as noted in Item 18a <br /> Pdnledrryped Nome Signature o Dgy <br /> EPA Form 8700.22 (Rev, 3905) Previous editions are obsolete. <br /> DESIGNATED FACILIT T DESTINATION STATE (IF REQUIRED) <br /> i <br />