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Please print or type. Form Approved , OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number <br /> WASTE MANIFEST CAL000399638 1 800-535-5053- INFOTRAC 0300043` 03 WAS <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> CLEANTECH ENVIRONMENTAL (CONTRACT #97709 ) <br /> 5820 MARTIN ROAD 1350 VINCI AVE . , STE 3 <br /> IRWINDALE , CA 91706 USA SACRAMENTO , CA 95838 USA <br /> Generator's Phone; 626 - 812-7200 <br /> 6, Transporter 1 Company Name U.S. EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC . CAL000399638 <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 ENVIRONMENTAL INC . CAL000330453 <br /> 5820 MARTIN ROAD <br /> IRWINDALE , CA 91706 USA <br /> Facility's Phone; 626-812 -7200 <br /> ga . 9b. U,$, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WI .Nol, <br /> 1 , NON - RCRA HAZARDOUS WASTE LIQUID ( USED ANTIFREEZE ) 1 TT G 135 i <br /> 0 <br /> Z 2. <br /> LU <br /> 3. <br /> 4 . <br /> 14 . Special Handling Instructions and Additional information <br /> 9B1 ) PROFILE #3589 - 135-02 USE GLOVES AND GOGGLES TANKER # <br /> ( USED ANTIFREEZE ) <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT: INFOTRAC 800- 535-5053 <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 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 Consent. <br /> I certify that the waste minimizalion statement identified in 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (If I am a small quantity generator) Is true. <br /> Generator's/Offoror's Printed/Typed Name Signature Month Day Year <br /> J 16. International Shipments <br /> r� 11Import to U.S. ❑ Export from U.S. Port of entrylexil: <br /> Z Transporter signature (for exports only): Date leaving U.S,: <br /> W 17. Transporter Acknowledgment of Receipt of Materials <br /> aTransporter 1 PfintedfTyped Name Signature / Month Day Year <br /> (/�11011, 61W e%e CP j '� r . � <br /> z Transporter 2 Prinledfryped Name Signature Month Day Year <br /> r- <br /> 18. Discrepancy <br /> 18anDiscrepancy Indication Space% �n Qluanlity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> ` v%mt C , Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> ua.. Facilily's Phone: <br /> Ll 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (i.e „ codes for hazardous waste Ireatmenl, disposal, and recycling systems) <br /> i . 2. 3, 4. <br /> 20. Desigr6A Facilily Owner or Operatorleltions <br /> calion of receipt of hazardous m covered by the manifest except as noted in Item 18a <br /> f Printe ped Name 1 t jai e—+ o Ye <br /> EPA Fo 700.22 (Rev, 12. 17) revouare obsolete. J DESIGNATED FA&4 I EPA's em#MANI EST SYSTEt <br />