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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUSLL�2_3 r 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 4jt7 L 0 18 6 8 2 7 9 2 JJ K 5.Generator's Name and Mailing Addresa GeN etdrs itd tl8re_55' f Aidnl Man mailing address) wl-v� � IC Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number CLEANJIT=r_'H Ei.VIP 3f,iEMEP:T 4Lj A1 I,0 3�R-8 .3E.- 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number CLEANT E CCt i ENtr`F.._Stt.t,;iENT;;L -- - - 20 iV?:'.G:Tiha QCs -E -j -00 Facility's Phone:�c• -8 :=-7,t�<= ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. -.=iIAZIIR n-3j_I:4 iJv,S T E _SLID(.�EISC)R:BEt�':TlPr..F'ER F" E`. r3'M SZ to?Eri k'! • M2. - - --- H. F:Ea-~.US;r;r,�.:`:TE _:C3LI 't�SIL v:_=LIi3�`�a�].S-Ei='_'E_% NIETAL 0IL FILTEf"S i � �) 3. 4. 14.Special Handling Instructions andAdd'io nformation S a _81'!PR=Fii_E 'E�3Fi_E+0�7� __ _.-, "_ U GLOVES AhiE3t= 3LE_T`.f k'E CF:LLLR:'rA_STIDENTIFY ?_RE'�t_Tt?LaT: lNFC;TFAC•,'_t'� - -- 15. GEN ERATOR'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, 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 EPA Acknowledgment 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. GeneratorslOHeror's Prinled/T ped Name Signatur Month Day Year ( ' t � v 1�q),,� (� o- 16.Interna conal Shipments F- ❑Import to U.S. ❑Export from U.S. ort of entrylexi z Transporter signature(for exports only): Date leaving U. w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintectTyped Name Sign re Month Day Year (L QTransporter 2 Printed(ryped Name MSignature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantityyp ElT e El Residue Partial Rejection EJ Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z Fn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certfcation of receipt of hazar o s materials covered by the manifest except as noted in m 18a Printed/Typed Name SignatureDay M lhar - �� I mk�) , k-0 I EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FA ILITY TO DESTINATION STATE(IF REQUIRED)