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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) wV 1d UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number 016698 0 WASTE MANIFEST (O&�3U 1.-eoo_b v;' 77 5. Generator's Name and MailingAddres�c�c,.,F G er tor's Sit d'iess di ant than mailing a ess) rUA V te�C7 M � (V "l/ �/t�% (.Q- Generator's Ph!:' t IV �CV\ � 6. Transporter 1 Company Name U.S. EPA ID Number 11 CLE.ANTECH Eh1�fIRONMENTAL OFA! D00,3681W 7. Transporter2 Company Name U.S. EPA ID Number 8. Designate Facilitf Name and ite Address HER ErWRONMENTAL SERM3CES LLC U.S. EPA ID Number n -rnr+-arc aeSn 284 EAST STOREY ROAD r3cka� r v �lVi COOLIDGE, AZ 85128 USA. 520-723-41677 Facility's Phone: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. 1. R4, NA3077, HAZARDOUS WASTE, SOLID, n.o.s., 9, PG III, (BRAKE DM P DO 18i 0 SHNANGS, CHROMIUM), (DO073, ERG#171 dt t-00 W_._. w... w.W ._uT.._......._... 2. L 3. 4. I i 14. Special Handling Instructions and Addition 361) PROFILE# �_ USE GLOMES AND GOGGLES TRUCK# c_ - (BRAKE SHAMINGS) CALLER MUST IDENTIFY CLE.ANTECH ENVIRONMENTAL .AS REGISTRANT. INFOTRAC 8M-535-5053 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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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. Generato' PrintedlTyped Name (---Signature Month Day Year r 1 'gel �� 2t- t F- 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials TransporteLPrintedAffi ed Name Signature Month Day Year O a zQ Transporter 2 Printed/Typed Name Signature Month Day Year H 18. Discre ancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: F 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U ra Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Print e ped Name Si Month Day Year , \ JCJ EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) wV 1d