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Please print or type, (Form designed for use on elite (12- itch) typewriter) Form Approved, OMB No, 2050.0039 <br /> UNIFORM HAZARDOUS 1 , Generator ID Number 2. Page 1 of 3, 1E'm�er nc R pons1 Pho a 4, M fe t u <br /> WASTE MANIFEST 1 bl�• I �- 2 7 JJ K <br /> 5. Generator's Name and Mal Address Generator's SiteAddress (if different then malting address) <br /> 30 w 1 1cttc N. of . <br /> Generator's Phone. <br /> e. Transporter 1 Company Name U.S, EPA ID Number <br /> CLEANTECH ENVIROMENTAL INC. CAL000368136 <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address CLEANTECH ENVIROMENTAL U.S. EPA ID Number CAL000330453 <br /> 5820 MARTIN RD <br /> IRWINDALE, CA 91705 USA <br /> 628w812"7200 <br /> Facilltyus Phone: <br /> ga, tib. U:S. DOT Description Qncluding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Tota) 12, Unit 13. Waste Codes <br /> HM and Packing Group (Ifany)) No, Type Quantity WI,NoL <br /> 1 . <br /> MEDIA) <br /> rip girt " M <br /> Ili T.19PA4 <br /> 7 <br /> 3.. <br /> 4. <br /> Yr <br /> 14. Special Hen dlin Insiruc8or>,S dit I,I atlon <br /> 9B1 PR�FILE# USE (3LOVESAND (30aCLES TANKER# <br /> (PAPER FILTER) V t <br /> CALL <br /> ER MUST 800.535.50537,%t <br /> IDENTIFY CLEANrECH ENVIROMENTAL AS REGISTRANT: INFOTRAC V <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 intemationaland national governmental regulations, If export shipment and i am the Primary <br /> Exporter, i certify that the contents of this consignment conform to the terns of the attached EPAAcknowiedgment of Consent <br /> (.certify that the waste minimization statement identified in 40 CFR 262,27(x) (if I am a large quantity generator) or (b) pf I am a small quantity generator) is true. <br /> G rator'slOfleror's Printed/Typed Nage % Signa Month Day Year <br /> .J 18. International Shipments <br /> 000, t,- ❑ Import to U.S. ❑ Export from U.S. Port of entrylexil: <br /> Va Transporter signature (fa exports only): Date leaving U,8a. <br /> 17. TransporterAcknowledgment of Receipt of Materiels <br /> Uri <br /> Ili <br /> Transported Pdnte (Typed Name Signature 11 Month Day Year <br /> Transporter2 Pdnla pe ame Signalu Mon17 Day Year <br /> i <br /> 18. Discrepancy <br /> I8a. Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> Now <br /> 18b, Alternate Facility (or Generator) U,S, EPA ID Number <br /> J <br /> V <br /> ►aL. Facilitys .Phorw <br /> w 18c. Signature of Altemate, Facility (or Generator) Month Day Year <br /> a <br /> z <br /> 1g. Hazardous Waste Report Management Method Codes (lies, codes for hazardous waste treatment, disposal, and recycling systems) . <br /> O 1. 2. 3. 4. <br /> i <br /> 20. Designated Facility Owner or Operator. Cefibellon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/fJiped Name Signature Mon h D Ye <br />� z ` <br /> EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY1p DESTINATION STATE (IF REQUIRED) <br /> I <br />