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Please print or iy as (Form deal ned for use on elite (12• Itch) typewriter.) Form Approved. OMB No, 2050.0039 <br /> UNIFORM HAZARDOUS 11 . Generator Number 2. Page 1 of er p 4. M t c u r <br /> WASTE MANIFEST l/ �t "r� 1 1. `59 4 4 JJ K <br /> 5, Ganeralor's Name and IngAddress L LIU Generators Site Address (if different than mailing address) <br /> GtfAEra94O(e• 9 ��-R • " / 1p , <br /> 6. Transporter 1 Company Name j U.S. EPA ID Number Voodoo <br /> CLEANTECH ENVIROMENTAL INC. CAL000368136 <br /> 7. Transporter 2 Company Name Flow U,S, EPA ID Number <br /> 8. Desighated Facility Name and Site Address CLEANTEC. H E(WIROMENTAL U,S. EPA ID Number CAL000330463 <br /> 5820 MARTIN RD <br /> IRWINDALE, CA 91705 USA <br /> Facili s Phone: 626-812=7200 <br /> 9a. . tib. U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group Of any)) No, Type Quantity WL/Vol. <br /> 1. <br /> c MEDIA) / / 00 <br /> 2 . <br /> F METAL OIL FILTERS) <br /> 3, <br /> 4, <br /> 14. Special Handling Instruction o Bon Viggo <br /> 9B1 )PROFILE# 9B2)pROF[L USEGLOVESANDGOGGLES TANKER/���!'" <br /> (PAPER FILTER) L L (METAL FILTERS) <br /> CALLER MUST iDENTIFY .CLEANTECH ENVIROMENTAL AS REGISTRANT: INFOTRAC 800-535.5053 <br /> 15, OENERATOR'SfOFFEROR'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 labeledlplacarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulations. Ilexportshipment and i am the Primary <br /> Exportegl certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. f <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(x) (it I am a large quantity generator) or (b) (if mall quantity g or e. <br /> en 0r Offerors Printed/Typed Na Signature Month Day Year <br /> 7Nos <br /> 6 <br /> 16. 1 ona[Z pments <br /> ort to U.S. ❑ Export from U.S. P of entrylexit. <br /> Transporter signature (forexports only): to leaving U.S.: <br /> 17, TransporlerAcknoWedgment of Receipt of Materials <br /> QTow,o ri 1 , Printedlly a Name Sig Month Day Year <br /> / <br /> Transporter ZPdntednyped Name S gnature 'Month Day Year <br /> 18, Discrepancy TV I <br /> 18a Discrepancy Indication Space Ego quantity ❑ Type ❑ Residua <br /> 0 Partial Rejection ❑ Full Refection <br /> Manifest Reference Number. <br /> = 16b:Ntemate Faciiity (or Generator) U.S. EPA ID Number <br /> c:> <br /> roti. Facilitys Phone: . <br /> W iso. Signature Of Alternate Facility (orGeherator) Month Day Year <br /> a <br /> z <br /> 10. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 01 . t ' \ 12, ro . 3. 4. <br /> l <br /> 20. Designated Facility Owner or Operator rUflcation of receipt of ha ous motorists covered. by the manifest except as noted In Item 18 <br /> Pdntedrryped Name Signature onth Day Ye <br /> fjq <br /> EPA Form 870,0 22 (Rev. 3.05) Previous editions are obsolete. I DESIGNATED FACILI TO DESTINATION STATE (IF REQUIRED) <br /> i <br /> i <br />