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Piaase print or type: <br />Form Approved. OMB No. 2050-0039 <br />EFTA Form 87GO-22 (Rev. 1 `6 VACK, IT Y TO <br />%-17}are obsolete. <br />WASTE 91ANIFE$T <br />CALO003990318 1 <br />3005355-5053-JNFOTRAC, <br />❑ 8 JjK <br />5. Gcnerplcrs Nameand Mading Address Gendralor's De Address (if Vkerent than mailing address) <br />CLCAi'FECH, ENVIROHME,"ITAL <br />5d320 1AARTIJ11 RD <br />iR`m INDAL—P, CA 91706 USA 1350 ViNc I Avc� 113 <br />626-911 2-72C[) SAOMMEINTO, c;, g581,6 USSA <br />C;eneralYa Prone: <br />G. rarrsporler 1 Company Name C1 F V,& EPA ID NufriWp <br />EMT E C H E M/ I R 0,M E N'TA L <br />I'Trarisplorter 2 Compaq flame U.S. EPA ID Number <br />A: <br />CLEANTECHENIVIROMENTAL Ll,& FPA ID Numbe, <br />5323 rVIAMIN RD <br />IRIPANDALE, CA 91765 USA <br />62&,`1 2 -12M <br />FaF.ilfty'5 Phone: <br />ga <br />9b, US. DOT Shipping Mame, Hazard Class, 10 Number, <br />'10. contzikners <br />IIJ04 <br />1Z Wirt <br />11 Waste Codes <br />Nal <br />Type. <br />HIM <br />vriGftckin�Group(ifany)� <br />quatity <br />wuvo�, <br />14 Spscial Handling. €15tFu-cinns and Additional. Informaton <br />1 PR USE GLOVES AND GOGGLES T*j I E�: <br />02 MILL <br />�, <br />CALLER FAUST IDENTIf `' C L EAN . MECH ENVIRONMIENTAL.X . 3:P.Da . ISTRANT` INFOTRAQ 800-535-5053 <br />.5. GEI� , ERATOWSJOFFEROR'S CERTIFIGATION: I hereby dEciare (ha�. (he voner� of ' accurately are fully,and arrately described above buy the proprshippinq name, ardare da$sifled, packaged; <br />MavW d and labelvd1placarded, and -are is vspemu in prow condilion to, transport 2=rding to applicable intemati . Gila] and naticral. gwernmeriW regulations, Jfexporl shipmed! and f aro €he F6mary <br />Exporter, i conify that the contents of this candprinehi urifdnn in the terms of the aachad EPA AckrqMedgrhell of Consiaril. <br />WaSIL lninJni7AiOn Statement idenAed In 40 C'FR 2132: ?{a) (if I am a lorge.quarrilly gerleptior) or (h) �Mam a small ctwantity paeralw) is Irde. <br />o �ff ' Prine�d-,Typed Name signal <br />f& e!ors Day <br />4J. <br />- <br />6. 11 bMa=iOM31 ShipMO <br />IQ� FIIS El Imporl 10 M. Export from U.S. Pu of erdryIeKiL <br />l— <br />E� <br />-­ " ' - L' - .. .. .. .. .. ... ... <br />Transpor',er signalum (for expom, only,): DMa leaving U.S.:: <br />ofI <br />not <br />17, cd RLcetplof Mlnjetia[s <br />I.- <br />PaVportw I Printedgyped Name Signature Mcnih NY Year <br />0 <br />;z <br />TranspodF 2 PfUednyped Name M.0nih Day Year <br />118. Discrepancy <br />18a, Discrepancy Indication Spac6Residue ❑ Prw Rwetio'l 0 Fell RejpOco <br />Manifest R6eterice Number. <br />16b,AJiernala Fa -114 (or Generator) J.S.'EPA ID Number <br />Zi <br />LL <br />Facility's Phone: <br />Signature ol'Afterrate. Failky (or Gerietator) <br />9crih ay Year <br />.S2 <br />19, Plazatdous YWistp Repor(ManagemeaMellhod Codes `(i.e., codes for hazardous waste F lwatmeRt, dlsposal, and recycling systems) <br />2 <br />1 <br />2. <br />13. <br />4, <br />20: De' igriatLd or OparatM Cerlificatfori of'mceipl of hazardous materials covered by the manKesi except as need in. Rem 18a <br />Signature , Pgonih toy Year <br />EFTA Form 87GO-22 (Rev. 1 `6 VACK, IT Y TO <br />%-17}are obsolete. <br />