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Please print or(ype. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number y <br /> WASTE MANIFEST �� 3 'Z� 0200227001 J K <br /> _ t An -FR 511.5.;-N-n �I <br /> S.Generator's Name and Melling Address he '� ener!� SF ille A s if difle I than mailing address) <br /> 5\GMAVO <br /> , iGenlols Phone: ` 4 tG�; <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CLEPJI ECH ENWROMEPITAL CAL00039OF-8 <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 /> GLEANTECH ENVIROA4ENTAL <br /> 5820 MARTIN RD CAL000330453 <br /> IRWINDALE,CA 91705 USA <br /> Facility's Phone:626-812-7200 <br /> ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, W.Containers 11.Total 12.Unit <br /> HM and Packing Group(irany)} 13.Waste Codes <br /> No. Type Quantity WLNoI. <br /> I' NON-RCRAFIAZAR.DOUS WASTE SOLID(ABSORBENT/PAPER,FILTE- <br /> o MEDIA) P 352 <br /> LWU <br /> 3. <br /> 4. I <br /> 14.Special Handling Inslrucli�onf�`j�' A n f rm lion �I <br /> 981 Ei. <br /> ' TJD'�' ^�lvnoncii r__. USE GLOVES AND GOGGLES 4110EF.; <br /> (PAPER FILTERS) vn "Eps, <br /> CALLER MUST IDENTIFY CLEAN T,ECH ENVIR011MVIENTAL AS REGISTRANT INFO T RAC 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 labeled/placarded,and are in all respects in proper condition for transport according to applicable internationaland national governmental regulations.If export shipment and I am the Primar7 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknov+fedgmenl of Consent. <br /> I certify that the waste minim¢alion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quanfly generafor).is We. <br /> Generator's70fteror's�PrintedfTyped Name : Signature -- month Day Year <br /> .. •...__.�-�_ ,. � <- <br /> 16.International Shipments <br /> F ❑Import Io U.S. ❑Export from U.S.,'' Port of chiry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: -- — <br /> w 17.TranspoderAcknowledgmenl of Receipt of Materials <br /> Transporter 1 PrinledlTyped Name Signal a booth Day Year <br /> O _ <br /> n- c- <br /> z Transporter2PrinledRyped ame Signatureh f,!on> pay ear <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quanlil T e <br /> Y ❑ yp ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> f� 18b.Alternate Facilily(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature ofAllemaFe Facilily(or Generator) <br /> tR <br /> Alonlh pay Year <br /> Z <br /> W19.Hazardous Waste Report Management Melhod Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> F�Gedificalion <br /> 3. <br /> 20.Designated Facility Owner or Opera( receipt of ha ardous materials covered by the manifest except as nded in Ilem <br /> Prinled/Typed Name Signature 1`1 in Year <br /> EPA Form 8700-22(Rev.12.17) Previous ed tons are obsolete. DESIGI IA•.l ED FACILITY TO Ef FIST SYS T UJI <br />