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Pleas print or type. - Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManifestTracking Number <br /> WASTE MANIFEST ` f 0200'.- 318 8 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CLE.ANTFt>f ENVIROMENTAL CALOW309M <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 /> HERITAGE ENVIROMENTAL SERVICES LLC AZD081705402 <br /> 284 EAST STOREY ROAD <br /> COOLIDGE,AZ 85128 USA <br /> Facility's Phone:520-7234187 <br /> 9a 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 Wt.Nol. <br /> 1' RO,UN1950,WASTE AEROSOLS,FLAK*AABLE,n.Q.s.,3.1 (PAINT, t >t P D003 331 <br /> o LUBRIC.ANTS),(13001),ERG*128 <br /> r <br /> LU 2. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 981)PROFILE#_--- USE GLOVES AND GOGGLES TRUCK0 _ <br /> (AEROSOLS) <br /> CALLER MUST IDENTIFY CLEANTECH ENVIROMENTAL AS REGI5TR/N Ti INFO T'RAC 800-536-SM <br /> 15. GENERATOR'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 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]ayi a small quantity generator)is true. <br /> Generator's/Offerors Prote yp <br /> ed Name Signature Month Day Year <br /> 16.Internationbl Shipment <br /> H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> CL <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> F}- 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> M 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />