Laserfiche WebLink
Please printer type.(Form designed for use on elite(12-pitch)tnosWriter.) Form Approved.OMR No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GenamlarlD Number - 2.Page i of 3.Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST I U&\--c-)004 Ii E:7 c c>c_ nc a_rs „ 013 5 31792 J J K <br /> S.Generators Name and Mailing Addrese r^y. Generators Sllo Ad different an ailing addmssl„ <br /> TML �?r11��C �1 �_ � •V �(''. � �Q JA''�1{�11UYY. '�3G1'll ) <br /> LA6.Transporter 1 Company Name U.S.EPA IO Numher I <br /> Cl-EP,NTECFi ENVIRONEMENTAL on, t, CAL000368136 <br /> 7.Transporter 2 Company Name S.EPA IO Number <br /> AW <br /> 8.Designated Facility Name and Site Address �r CU.S.EPA ID Number <br /> I..EANTECH ENVIRONMENTAL '.' -, � .,:3aALU:J03:1G453 <br /> 5820 WATIN RD <br /> IFVMY NDALE.CA 91706 USA ENVIRON1',icivTAL <br /> Facl9ys Phone: 626-812-7200 <br /> 98. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Ph ars 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNo1. <br /> K 1. IVOWRCRA.HAZARDOUS WASTE SOLID(.ABSORBE9I1'/P4,PER FILTE DM P 352 <br /> 0 MEDIA) <br /> w 2• h1ON-RCRA HAZARDOUS WASTE SOLD(OILY SOLID WP STE/USED DM1 352 <br /> METAL OIL FILTERS) a. U� <br /> 3. NON-RCRA HP20RDOUS WASTE SOLID(USED ABSORBENT) CII P 352 <br /> 4. <br /> 14.Special Handling Instructidhslpl) rdl 0 6 forme8oh ,I/.J �, <br /> 9B1)PROFfLEA` (( VV_�6_9B2)PROPIt-C-pfY B3)PROFILEab _USEGLOVESAhID GOGGLES TAfdHERYf, c'r-- <br /> (PAPER FILTER) (NIETAL FILTERS) (USED ABSORBENT) <br /> GALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REQSTRANT:INFOTRAC 800-535-50533 <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 /> marred and labeledlplacarded,and are in all respects In proper condition for transport according to applicable Intema8onal and nallonai governmental regulations.Rupert shipment and I am the hmary <br /> Exporter,I cortlly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I coNly that the waste minimization statement Identified In 40 CFR 282.27(a)[if I am a large quan8ty generator)is(b)(If I am a small quan8ly,generator)Is true. <br /> Generatoes/Offemrs PdNedRyp d area Signature^ ` Month gay Year - <br /> IN.��t �� <br /> .rj 1s.Intematlon iShipments <br /> F ❑Import to U.S. El Export from U.S. Por of entrylextt: <br /> z Transporter signature(for expans only): Date leaving U.S.: <br /> 17.TransporerAcknowledgmenl of Receipt ofMaledals <br /> rra Signature ' ' /i'� 7 Month 0aY Year <br /> Tmrsporer 1 PrntedRyped Name 7 I „• <br /> CL (�_.�"-` j/ -^ L // h tom•' V 'C.1 <br /> N - _ `b-./( c v Monm gay Year <br /> Tmnspodar2 PnnledRyped Name `-' 'p.-�_ Signaturef/� <br /> -C Uy <br /> r <br /> I <br /> 18.Discrepancy18a.Discrepancy Indication Space ElQuantity ❑Type L1Resldee ❑Partal Rejection ❑FurRefection <br /> Manifest Reference Number. <br /> 18b.Alternate Facillty(or Gamma or) U.S.EPA ID Number <br /> J <br /> U <br /> aa+. Facility's Phone: <br /> Qw 18c.Signature ofAitemats Facfily(orGaneretor) Month Day Year <br /> Z <br /> i <br /> 19.Hazardous Waste Repot Management Method Cedes(i.e.,cedes for hazardous waste heaenan4 disposal,and recycling systems) <br /> y 1 4. <br /> 0 1 'I 1 I )ki��U ' <br /> 20.Designated Facility Owner ar Operac Certification of receipt of hAardous materiels covered by the manifest except as'note d in Item Ise <br /> Pdnted(Typed Name Signature Month Day Ye r <br /> EPA Form 8700-22(Rev.3.05) Previous editions are DeaDlete. I&SIGNATED FACILITY TO GENERATOR <br />