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Please print or type. Form Approved.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 C,;�-t-CCO T-A 4 g 1 1 800-535-5053-INFOTRAC p 3 6 D 15 6 9�2 WAS <br /> 5,Generator Name and Mailing Address e-e-6 Cd y,; - A Iner I�o is_ re (i erent than mailing address) <br /> �tl�D�,D ►s►s w <br /> Generators Phone: je ❑h }4' 3 to <br /> 6.Transporter 1 Company Name U-S-EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. CAL000399638 <br /> T.Transporter 2 Company Name U-S.EPA ID Number <br /> B-Designated Facility Name and Site Address US-EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. CAL000330453 <br /> 5820 MARTIN ROAD <br /> IRWINDALE,CA 91706 USA <br /> Facility's Phone: 626-8.12-7200 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit i3.Waste Cedes <br /> HM and Packing Group(if any)) No. Type Quantity WI.Nol. <br /> 1. - — <br /> Q <br /> LU <br /> � 2. NON-RCRA HAZARDOUS WASTE SOLID (ABSORBENT/PAPER Dill P 352 <br /> LU <br /> FILTER MEDIA} <br /> 3. (911=4 991=11)WAS:PgA 12F�0 QM 25:2 <br /> 4. <br /> 14.Special Handli Instructions and Additional Informalion <br /> 9B2]PROFILE# USE GLOVES AND GOGGLES <br /> (PAPER FILTER) -S) -- <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT: INFOTRAC 800-535=5053 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that Ure contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of[his consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimi zalion 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 /> Z <br /> lor'sfOfferoes PrintedfTyped Name Sign ture r Month Day Year <br /> I Iz et) I } <br /> 16.Intemalloaal S11Wnts <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports only): to leaving U.S.: <br /> W 17-Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> I-- Transporter 1 PrintedfFyped Name Signature Month Day Year <br /> n. <br /> rC 1Z 2@ t <br /> Z Transporter 2 PrintedfTyped Name ure Month Day Year <br /> w <br /> 1 B.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Typef j <br /> Residue Partial Re'ection Full Rejection <br /> Manifest Reference Number: <br /> Fes. 18b.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> U <br /> Facility's Phone: <br /> LU 18o Signature of Alternate Facility(or Generator) Month Flay Year <br /> a <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e-,codes for hazardous waste treatment,disposal,and recycling systems) <br /> A 1. 2. H1q 3 4 <br /> 20.Designated Facility Own or Operator:Certification of ipt of hazardous materials covered by the manifest except a cited in Item 18a <br /> PrinledlTyped Name �^� Signature1:1-\/ �r.l• <br /> V 1 <br /> EPA Form 8700-22(Rev.12-1 reviouseditions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />