Laserfiche WebLink
Please print or type. Form Approved.DMB No.205041039 <br /> UNIFORM HAZARDOUS 1.Ganeralor ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST A]--COLI,-5 '77 1 800-535-5053-INFOTRAC 030005014 WAS <br /> S.Generator s Name and Mailing Addresse-,-3cc) yv s ?�qq � ss(if different than mailing address) <br /> �( 1 <br /> f5-IT- Row Pr--. � <br /> � <br /> ` l c n GPC 5 34aCP <br /> A n <br /> GeneraWrs "e- <br /> B.Transporter 1 Comparry 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. CAL000330453 <br /> 5820 MARTIN ROAD <br /> IRWINDALE.CA 91706 USA <br /> Facilif s Phone: 626-812-7200 <br /> ga. 9b.U.S-DDT Descr ption(including Proper Shipping Name,Hazard Class,ID Number, 10-Containers 11-Tola€ 12.Unit 13.Waste :odes <br /> HM and Packing Group(if any)) No, Type Quantity Wt.fvol, <br /> 1. E-D-AB&ORBENT) -- ------...-•----- DM P-.. 352 - f <br /> a <br /> rz <br /> 2. NON-RCRA HAZARDOUS WASTE SOLID (ASSORBENTIPAPER DM P 352 <br /> FILTER MEDIA) <br /> 3. <br /> METAL <br /> IJ CII TEFQS) 1 <br /> �.-..� - fill <br /> I <br /> 4. <br /> - I I <br /> 14-Special Handiingg Instructions and Additional lnformaGon r <br /> 9Bfi�Ri�BF1-- --- 9B2)PROFILE# USE GLOVES AND GOGGLES <br /> IAVC!' RRE4ITl (PAPER FILTER) � <br /> 'MAII � <br /> C � <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT: INFOTRAC 800-51V3155=5053 <br /> 15, GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contends of this consignment are fully and accurately described above by the proper shipping name,and are dassifed,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and nalional governmental regulations.If export shipment and€am the Primary <br /> Exporter,I certify that the contents of This consignment conform to the terms of the allached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified in 4a CFR 262.27(a)(ff I am a large quanlity generator)or(b)(if I am a small quantity generalor)is true. <br /> GenerateslOfferoes PrintedlTyped Name f Signa re Monlh Day Year <br /> Ito `j 1 ;C' <br /> I <br /> 1 ,Inlernational Shipments <br /> F ❑Import la U.S- ❑Export from U.S. "Port of enlrylexit: . <br /> ? Transporter signature(for exports only): Dale Leaving U.S.: <br /> X 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 Transporter 1 PrinledlTyped Name gnalure Month Day Year <br /> ,c _ /01 -5 <br /> z Transporter 2 PrinledlTyped Name Signalu Month Day Year <br /> a <br /> x <br /> 18.Discrepancy <br /> 18a.Discrepancy Ind icalion Space ❑ Quantity ❑Type <br /> ❑Residue Partial Rejection ElFull Rejection <br /> Manifest Reference Number: <br /> � <br /> 18b.Alternate Facility(or Generator} U.S.EPA ID Number <br /> J_ <br /> U <br /> Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generador) Manth pay Year <br /> F— <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ra 1. 2. 1-1 I F 4, <br /> 20.Designated Facility Owner or Operator:Certification of receiptqPazardous material vered by the manifest except as noted irillern 18a <br /> Printedlfyped Name Signature Month Day Year <br /> EPAForrn 8 G0-22(RevJ2-17) Previous editions are obsolete. Q SIGNATED FAVLITY TO EPA's e-MANIFEST SYSTEM <br />