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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Num r { 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFESTV _ 1 800-535-5053-INFOTRAC 0 3 0 0 0 5 0? 3 WAS <br /> 5.Generator's Name and Mailing Address '.. 1�,o gya{or,$}(e Address([differ t an m fling addr ss) ty <br /> I S 1 S I o-lo PF 'D r. r rJ` "I} .P2�cA <br /> ' �0 <br /> Generalor's Phone: x Q A j a (r7 ' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. CAL000399638 <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. <br /> 5820 MARTIN ROAD CAL000330453 <br /> IRWINDALE,CA 91706 USA <br /> Facility's Phone: 626-812-7200 <br /> ga, 9b.US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> RG— No. Type Quantity WuVol. <br /> 1 .roe, r on un�nRp©US WAS�ESOL�[3-(1JSEBA$SpR DM P 352 <br /> 0 <br /> ----------' — <br /> ~ <br /> 2. NON-RCRA HAZARDOUS WASTE SOLID (ABSORBENT/PAPER P 352 <br /> co FILTER MEDIA) <br /> i <br /> 3. R9814ru WASTE SOL{ IiAS96JD-WASTE-/1JS€D- —DM—---—.P--- 352-._:._._. <br /> i <br /> 4. i <br /> i I <br /> 14.Special Handlingg Instructions and Additional Information , <br /> 9917 O��E* 9B2)PROFILE#,)Ol 0- USE GLOVES AND GOGGLES <br /> (PAPER FILTER) 9$3) ( LT�n�41 T <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTALAS REGISTRANT:INFOTRAC 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 international and national governmental reggfolions.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[he[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 gerfeT tor>is true. <br /> Generator's/Offerors Prinledlfyped me Signe fee ) <br /> �� /" / / � Month Day Year <br /> 16.Intemallonal Shipments <br /> F- ❑Import to U.S. ❑Export from U,j' Port of entryl il: <br /> K Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.TransporlerAcknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Prin(ed,Typed Name S'nature--'— Month Day Year <br /> Z Transporter 2 Printed/Typed Name Signa ur Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity El Type E]Residue El Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> v <br /> L Facility's Phone: <br /> LO 18c.Signature of Altemale Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. 3 4. <br /> 20.Designated Facility Owner or Op or.Certification of receipt o zardous materials covered by the manifest except as noted in 114 18a <br /> PrinledlTyped Name Signature Month Day Year <br /> I HI/Ku,b. r b Iq <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. D.SI 'NATED FACILITY TO EPA'S 0-MANIFEST SYSTEM <br />