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Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Manifet TIdNumber <br /> WASTE MANIFEST t L J - �3b 0'1'9'7 4 9 4 JJ K <br /> 5.Generator's Name and Mailing Add �,- ,,Op',�pta� Address(if different than mailing address) <br /> Am <br /> Generator's Phone; <br /> 6.Transporter 1 Company Name U.S.EPA ID Num t <br /> M/0003 <br /> CLEANTECH EWIRONMENTAL INC <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 /> CLEANTECH ENVIRONMENTAL INr Ci,Lt70G330ai <br /> 5820 MARTIN ROAD <br /> IRt+UiNDALE,CA 9170£USA <br /> Facility's Phone: 825'812-7200 <br /> ga. 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 M.Nol. <br /> It 1. zeP a52 <br /> 0 n tELQ6 i <br /> L 2 NON-RCRA HAZARDOUS WASTE SOLID(OILY SOLID WMASTElUSED DM P 353 <br /> METAL OIL FILTERS) <br /> 01411 P 462 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information _ <br /> 92@)PROFI y USE GLOVES AND GOGGLES TANKERTiQ <br /> (METAL FILTERS) _ <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT:INFOTRAG 800-535-5053 <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 labeledlplacarded,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 EPAAcknowledgment 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)(ifI am a small quantity generator)is true. <br /> Genera rsl or s Pr nce ,ANS e/ Signature Month Day Year <br /> V! i <br /> 16.International Shl ments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt Materials <br /> Transporter 1 Prmted17yped N me Sign re Month Day Year <br /> 4 d ! <br /> Z Transpo er 2 Printed/Typed a Signature Month Day Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue 1 ❑ 1 <br /> Partial Rejection Full Rejection <br /> 1 <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: i <br /> W 18x.Signature of Alternate Facility(or Generator) Month Day Year <br /> t <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1 2. �� 3. 4. ' <br /> F <br /> ated Facility Owner or Operator Certification ofceiptof hazardous material covered by the manifest except as nde i Item 18a <br /> ed Name Signature onth Da Ye r <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. IGNATED FACILITY TO EPA's L%-MANIFEST SYSTEM <br />