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Please print or Noe. <br />FormAooroved" OMR No 2050-0039 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />DE IG ATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />UNIFORM HAZARDOUS <br />I 1. Generator ID Number2. <br />C-At!CCC13�(�j`�-j� <br />Page 1 of <br />3. Emergency Response Phone 4. <br />Manifest Trackin Number <br />019 42646 <br />WASTE MANIFEST <br />}v ^� <br />JJ K <br />5. Generator's Name and Mailing Address 1 � General��Siteddre (if diffe enithan mailing (address) 1 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number ,,,34,0,,✓v <br />CLEr' NTECH Erd'.°IRS_ NNIIENTAL INC - <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U.S. EPA ID Number <br />Cl EANTECH EN%'1Rt OMENTAL INN <br />cn- p.ART!, P&`-1,D1'rLOt3033+iz1S•� <br />_� ,ytId <br />Io;u R',,°:tINGALE, CA. 91705 I I&A• <br />Facility's Phone: 6£6-81'1-7''200 <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any))13. <br />Quantity <br />Wt.Nol. <br />0 <br />1. <br />LU <br />LU <br />Z <br />LU <br />2. <br />kJ N-RCR:6-•. HA? iREVDUS 'AlA...STE SOLID `OILY SOLIG'P.ASTE!I !`9ECr <br />C-ivl <br />F <br />36•'? <br />c7 <br />MET AL OIL FILTERS-) <br />3. Ar-.i iWg"-A;6t^_:'c SOL.- .- :, ,car, <br />4. <br />14. Special Handling Instructions and Additional Information <br />-=LA44:P?9F-1L999 92B)PP•OFILEW-'14,�V�,==��I�€rt LI. EGLCJ-.JESANDGOGGLES TA,NE;cF��i <br />'' E-1 iNIETA.L FILTERS) L3 7B .z.0 <br />CALLER MUST IDENTIFY CLEANTECH ENkAIRONIv1ENTA.LAS REGISTRANT: INFOTRAC: 800-535-5053 <br />15. GENERATOR'S/OFFEROR'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 minimization statement identified in 40 CFR 262.27(a) (if I am a large q ator orb (if I am a small quantity generator) is true. <br />Generator's/Off led/Typed Name ignature Month Day Year <br />j <br />~ <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />? <br />I Transporter signature (for exports only): to leaving U.S.: <br />W <br />UJ <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printedffyped Name Signatu <br />Month Day Year <br />0 <br />CO <br />Transporter nntedfType ame Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantit Type y El El Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />H <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />0 <br />LL <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />1 <br />05 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />� <br />1. <br />. <br />2. <br />I k,�o l0 <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Ce 'fication of receipt of hazardo materials covered by the manifest except as noted in I 18a <br />Printedffyped NameLMonth D Ye <br />`� <br />. �� 1 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. <br />DE IG ATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />