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Please print or type. (Form designed for use on elite (12-pltch) typewriter.) Form Approved. OMB No. 2050-00; <br /> JUNIORMHAZARDOUS 1 . GeneratorID Number 2. Page i of 3. Emergency Response Phare 4. Manifest Tracktncg Npumber <br /> STE MANIFESTO1HUS 5 JJ KVORN <br /> eretor s Name and Mailing Address ©�� g n 1: rkr `,,,,, afo�'s fe ddre ' If dtertTtftan mailing address) <br /> I of <br /> Generator's Phone: �fl C W <br /> 6. Transporter i Company Name U.S, EPA ID Number <br /> CLEANTECH EWIRONEfvIENTAL C,AL00036f? 12S <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 /> CLEANTECH EM11RONMENTAL <br /> 5820 MARTIN RALQ00330I63RD 3 <br /> 1RNVINDALE , CA 91706 USA <br /> FaciiiVs Phone: 626-$ 12-7200 <br /> gas 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit - <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nolb 13. Waste Cartes <br /> rx <br /> 1 ' NDN-RCRA t tAZARi3.'S" US WASTE SOLID (.AOSORBENT/PAPER FILTEF DM P 352 <br /> IViED1A) <br /> W 2' NON-RCRAHAZARDOUS WASTE SOLiD (OILY SOLID WASTF, USED CJ DM P 352 <br /> 0 METAL OIL FiLTERS) (Ot <br /> 3. ?r 0 _ — <br /> she <br /> 4. <br /> 14. Special Handling Instructions andAddiffonal Information- <br /> 9B1 )PROFIi_E# 982)PROFILE## USE GLOVESAi+IDGOGGLES' TtWKER <br /> (PAPER FILTER) (h".EMAL FILTERS) 99QRF rrti IT;l <br /> CALLER MUST IDENTIFY CLEANTECH EfOVIRONMENTAL AS REGISTRANT: INFOTF`AC 800-y35-5053 <br /> 16. GENERATOR'SiOFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershlpping name, and are classified, packaged, <br /> marked and dabelediplacarded, 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 confdrm to the terms of the attached EPAAcknowledgment of Consents <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (if I am a small quantity generator) Is true. <br /> 111 <br /> Generator'sne.PdntediTyped Name Signatur Mon Day Year <br /> :a 16. interna hipments <br /> F- ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit• <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> 17, TmnsporterAcknowiedgment of Receipt of Materials <br /> oTransporter 1 PdntediTyped Name Signa re Mo Day Year <br /> CL <br /> j z Transporter PrintednWed Name Signature <br /> ¢ Month Day Year <br /> I t' <br /> k 18. Discrepancy. <br /> ifla. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection , ,- ❑ Full RejectionMiss . <br /> C Manifest Reference Number <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> Insists <br /> I uQ- Facllitlls Phone: <br /> UJ <br /> 18c. Signature of Alternate Facility (or Generator) Month Day Year. <br /> Q . <br /> CD <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> LIJ p 1 • T <br /> 3* 4.milli <br /> - <br /> 20. Designated Facility Owner or Operator. Ce ' tion of receipt of hazardo maledais covered by the manifest except as noted in Item <br /> z PrintedlTyped Name Signature Mon �Dayy r <br /> ` <br /> !/tib <br /> E `EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACT ITY TO DESTINATION STATE (IF REQUIRED) <br /> I <br />