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Please print or type, Form Avroved,OMB No.2050-0639 <br /> UNIFORM(HAZARr7fl115 1 Generafo 10 Number 12,Page 1 of 3,Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE N)ANII C L o L4 x.27 �1`� 1 500-535-5053-INFOTRAG 03001621-14 WAS <br /> 5.Ganeralo s'Jame and Mailing Address r7�L' r nL+ ] rocs(if dlRereni Chan mairing address) <br /> 1S k5 DS-, <br /> Gens ralo�s Phoney `? Ci e� r CA _1 s s�n�- <br /> 6.Tfanspader 1 Company Name U.S.EPAID Number <br /> CLEANTECH ENVIRONMENTAL INC. CALOOD399638 <br /> 7.Transporter 2 Company Name U.S.EPA I6 Number <br /> B.Devgnaled FacNly Name and SO Address U-S.EPA ib Number <br /> CLEANTECH ENVIRONMENTAL INC. <br /> 5620 MARTIN ROAD CAL000330452 <br /> IRWINDALE.CA 91705 USA <br /> Facility's Phdrie; 676.612-7200 <br /> ga- Bb.U.S,DOT Desc000n(-mc6ting Proper Shipping Name,Hazen:Class,ft}Number, 16.Conlainers <br /> HM and Packing Group(if any)) 11.Total 12,Unll 13.Waste Cad=s <br /> No. Typa Guanlity VVY01 <br /> T -fBm��n�"r+"r 'r"r��r r iar�R��S 7LI�]�l�a�B A8&F7H$EfV� M— P--—3 <br /> 4 <br /> iu <br /> w 2. NON-RCRA HAZARDO S WASTE SOLID (ABSORBENTIPAPER DM P 352 <br /> c� FILTER MEDIA) r <br /> cc, <br /> 3. —NON-RGRA-HAZ-ARDO 1S-WA&7C—SC3L-}D IL-Y--SOL-IR-WA&T.G;USE-DL —E1hA—-. —.P—.—.352--i <br /> dAL�3{I=-�Lk�=Ti Si <br /> 4. <br /> 14-Special Itandrrn lnstruclions and Additional Inforomllon <br /> 9f32)PRQFILE# USE GLOVES AND GOGGLES <br /> (PAPER FILTER) <br /> CALLER MUST 10ENTIFY CLEANTECH ENVIRONME NTAL AS REGISTRANT: INFOTRAG 800-535=5053 <br /> 15- GENERATOR'WOFFEROR'S C ERTIRCATI ON:I Wreby dedam Inal the cnnranis of this ccmagnmonI Lite tiny and accuraleiy de5enbed above by rbc propershipping name,and eredassilied,packaged, <br /> marked and libeledlpiacarded,and are in all respects in proper condilm for frampod according to appriYahle Inlernalmnaranot nalmnal governmental regulations.If upon shipment end I am the Primary <br /> E%parier,I cartlfy that the contents o!This consigrrnenl confwm la the Terms of Ilie ahached EPA AcknowiMgmenl.at Consent. <br /> I certify that the vraslamirimrlaalion slatemcnl idenOFed In 40 CFR 262,27(a)(if I am a Wye quantity generator)or(b)(Y f am a small guanilty gerwatorl is True. <br /> Gen aloesfolfe(dfs PrfnWl d Name [ / Sig h Month Day Year <br /> 16.Inlamalional Shfpmer ❑Import In U.S.i— ❑Eatpo from U-S- Pari of enlryfexlr' <br /> ? Transporter signalura(far expom only): le leaving U-5' <br /> W 17.Transpgderkknm-AdgmeniofRecefplofMal?rats <br /> LLF <br /> TfanslawlerI Pnnleffyped Name Signolure Mallh Day Year <br /> D <br /> CL <br /> c cS �-- l Z-0z.3 � <br /> Transporle'7 PrintedrTyped Name Sia loge Unnlh pay Year <br /> 4 <br /> a <br /> H <br /> 10-discrepancy <br /> 18a.Discfepancy Indicalion Space <br /> pfranldy ❑Type ❑ftesidrre ❑ParGarrpn <br /> RcjeG� ❑Fu11 Rejection <br /> ManifeM Referents Number. <br /> F 18b.Allemala Fadrily(dr Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facil ty's Phone <br /> LU IOc,Signalute of Allo male Faclily(or Generalof) <br /> Qr f. nlh Day <br /> Yea: <br /> ! <br /> 19,Hazardous Wasie Report hianagemenl Nefhvd Codes(I,e.,codel for hazardous waste uealmenl,disposal,and recyeinig systems) <br /> p I• 2. 3, 4- <br /> I/ <br /> 20_Drsignated Facility pruner or Operale- rlifita2n of receipt of hear ous maicrials covered by iha manifest except as nxed in Ifo a <br /> Pdnredrfyped IVania S gna(ure f tooth 0 y Year <br /> EPA Farm 8700-22(Rev.12-17) Previous editions are absolefa. LIES C, ATE13 FACILITY TO EPA's e-If1ANIFEST SYSTEFA <br />