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Please print or type. Form Approved , OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS Ill Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST 1 800-535-5053 - INFOTRAC WAS <br /> 11111 <br /> 5, Generators Name and Mailing Address © ; ' ro p Generator's Site Address (if different than mailing address) <br /> 0301 W (C,?(A V.¢rm40v` t.,n/ <br /> Generators Phone: U CQI C 9S 42100 1 <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 . <br /> 5820 MARTIN ROAD CAL000330453 <br /> IRWINDALE , CA 91706 USA <br /> Facility's Phone: 626-812 -7200 <br /> ga 9b. 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 (if any)) No. Type Quantity WI.NoI. <br /> 1 , NON -RCRA HAZARDOUS WASTE SOLID ( USED ABSORBENT) DM P 352 ! <br /> 0 <br /> Z 2. NON - RCRA HAZARDOUS WASTE SOLID (ABSORBENT/PAPER DM P 352 <br /> FILTER MEDIA) <br /> 10� <br /> I <br /> 3, NON -RCRA HAZARDOUS WASTE SOLID (OILY SOLID WASTE/USED DM P 352 ! <br /> METAL OIL FILTERS ) <br /> 4 . +I <br /> i <br /> 14. Special Handling Instructions and Additional Information <br /> 961 ) PROFILE # 962 ) PROFILE# USE GLOVES AND GOGGLES <br /> ( ABSORBENT ) ( PAPER FILTER ) 9B3 ) ( METAL FILTERS ) <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT: INFOTRAC 800- 535 = 5053 <br /> 15, GEN ERATOR'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 EPAAcknowledgment of Consent. <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 /> Generaloes/Offerors Pfinled/Typed Name Signature Month Day Year <br /> �' . 11 (91 ' <br /> 16. International Shipments <br /> F— ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> ? Transporter signature (for exports only): Date leaving U.S. : <br /> W 17. TransporterAcknowledgment of Receipt of Materials <br /> LU <br /> 2 Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 <br /> 17 1 (9 1 l <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type Residue <br /> El Partial Rejection ❑ 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 of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> W 19. Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 . 2. 3, 4 . <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700.22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />