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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Apprc <br />UNIFORM HAZARDOUS 1 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST j ! <br />5. Generators Name and Mailing Address Generator's Site Address if different than mailingaddress <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />CLF-AINTECH-NR4!P0N1EFaEp,1T.e0 <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 />EANTECH ENWIRONMENTA.t <br />0820 ti1ARTIN RO <br />IFdb'`i'^,ll?A.I-.F, CA 9 1 T OF <br />FariliW, Ph—. - 1.. <br />OMB No. 2050-0039 <br />JJK <br />DESIGNATED FACILITY TO GENERATOR <br />I <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wl.Nol. <br />13. Waste Codes <br />No. <br />Type <br />O <br />a <br />{}► y <br />64 <br />W <br />CidAa-tk�iLaOUS WASTE SOLID (OIL'Y' SOLID W,f STEr- <br />:;i;:TAL OIL FILTERS} <br />_ <br />3 <br />4. <br />14. Special Handling Instructions and Additional Informationn 7 <br />FMGTALF!LTERSj <br />- .I:ANTECH L(IVIRONMENTAL AS RMSTKANT: WFOTRAC 800-535-505 <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 quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator's/Offeror's Pdnted/Typed Name Signature Month Day Year <br />Z <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port <br />— <br />of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />0 <br />CL <br />Transporter 1 Printed/Typed Name Signature j1 i trr, Month Day Year <br />Cn <br />1(l <br />aZ <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full <br />Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />M <br />U.S. EPA ID Number <br />V <br />LL <br />Facility's Phone: <br />M <br />18c. Signature of Alternate Facility (or Generator) <br />Q <br />Month Day Year <br />Z <br />W19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 <br />2. <br />3. <br />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 />Printed/Typed Name �- Signature Month Day Year <br />FPD <br />Fnrm R7nn_79 to— Q nr;1 <br />DESIGNATED FACILITY TO GENERATOR <br />