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Please print or type. FormApproved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 BOO-535-5053-IN FOTRAC 030004991 WAS <br /> 5.Generator's Name and Mailing Address5'pe-A--d GU I t{ (L { `MAN tui lg,gddress(if different than mailing address) <br /> D�OaVi7r S t�p'r� � �N it <br /> Generalor's Phone: r O!` r-t %C?-55("o <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. CAL000399638 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. CALQ00330453 <br /> 5820 MARTIN ROAD <br /> IRWINDALE,CA 91706 USA <br /> Fadlitys Phone: 626-812-7200 <br /> ga. 9b.U.S.DOT Descrfplion(induding Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Totat 12,Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)] No. Type Quantity VJI.Nol. <br /> 1• ._IIIYPIRGR IJn7no-0-1185n1n BSORBEN_ _ —1)M _. P 3552 <br /> t� r <br /> LL <br /> � I <br /> 2. NON-RCRA HAZARDOUS WASTE SOLID (ABSORBENTIPAPER DM P 352 <br /> c7 FILTER MEDIA) 9 <br /> 3. _.NON�RCRA.HAZARDOUS.WASTE-SOLID-{OILYSOL{D-WASTEIUSEQ - - —DM P 352 <br /> METAL OIL FILTERS} <br /> i <br /> I <br /> 4, <br /> 14.Special Handifn 1nsW9 <br /> ions and Additional Information 132}PROFILE#3��qq 1 y•_ 352-01 <br /> 9USE GLOVES AND GOGGLES <br /> PAPER FILTER) <br /> CALLER MUST IDENTIFY CLEANTECH E NVI RON ME NTAL AS REGISTRANT: INFOTRAC 800-535=5053 <br /> 15, GENERATOR'51QFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aril are classified,packaged, <br /> marked and IaVI"ptaearded,and are in all respects in proper condilion for transport according to applicable intemawnatand national govemmental regulations.If export shipment and I am the Primary <br /> Exporler,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minfmizafion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if t am a small quantity generator)is true. <br /> Gen oesloff rialedlfyped Name natur Month Day Year <br /> Ur7 f•L{ 1171 (5 <br /> 16.Inlernatio I Shi nts <br /> ❑Import to U.S. Export from U.S. Port of entryfexit: - . _ <br /> z Transporler signature(for exports only): Date leaving U.S.: <br /> tr 17-Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 PrintediTyped Name Signature Month Day Year <br /> Z Transporter 2 Printed/Typed Name '� � � <br /> Signa— Month Day Year <br /> 18-Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity ❑TypeEl j j <br /> Residue Partial Rejection Full Re edion <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> udFacitiVs Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day <br /> Q <br /> a <br /> u5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> 20,Designated Facility Owner at O rator:Certification of receip hazardous materials covered by the manifest except as noted lem 1 ea <br /> PrintedlTyped Name Signature MA6 I ffi-Ve b 1onth.1, uj�Akb " Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. IGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />