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601114 <br /> Please print or type. ""CU Y � "> Form Approved.OMB No.2050-003! <br /> S 1.1:Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trac kln Number <br /> WASTE MANIFEST r ��-� c 019 s o y JJ K <br /> tTUNIFORM HAZARDOU <br /> Generators Name and Mailing Address c.� �� Gene ors t dress(if 'ffere t th ailing ddr s ! '4�' a <br /> CO �. k - 1011 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> (,LEANTE:H EN`JAROMEN7AL. INC, CAL000368136 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site AddressU.S.EPA ID Number <br /> CLE:ANTECH EiV�!llFtf}i1'IFNTFYI. .t CALQ0+�330453 <br /> 5820 MARTIN RE) <br /> !RVQ"NDALE,CA 91705 USA <br /> Facility's Phone: 6254)12-7200 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Ncl. <br /> 1• NOI+RCiRNHAZARDOUS WASTE SOLID(ABSORBe,171PAPEF{FILTER DM P 352 <br /> p MEDIA) <br /> ZZ <br /> 2. NON-RCRA HAZARDOUS WASTE SOLID(OILY SOLID WAS'TE/USED DM � r7 352 <br /> c� METAL OIL FILTERS) C JLC(D <br /> 3.__.-P�`hl-F3GfoA.kdAZA3��7s'�!'+?��-F�+E+i-Ii�?�(G� u'J-AIBSAR-�"T�..._. ._.._. _ ._.•_.${u9 ._._------ <br /> P 362 <br /> 4 T- <br /> 14.Special Handling Instructions and Additional Information <br /> 8B1)PROFII_EAI 7- 62)PROFILE#I�f USE GLOVES AND C3CK3C3LES Tf�PNCE <br /> (PALER FILTER) (METAL.FILTERS) : A7" <br /> CALLER MUST IDENTIFY CLEANTECH EWIROMENTAL AS REGISTRANT: INFOTRAAC: 800-535-5053 <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 /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemaZnalan. conal go ntal regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of I certify that the waste minimization statement identified in 40 CPR 262.27(a)(H Ia n a large quantity generator)or(b) ity generator)is true. <br /> Generator'slOfferoes Printed/Typed Name Signature -Morth Day "ea <br /> 16.International Shipments 0 Import to U.S. ❑Exeort frorr9 Port of entry/exit: <br /> zDate leaving U.S.: <br /> Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed(fypsd Name Signa re I Mo D� Yea <br /> a <br /> la <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Yea <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue 0 Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> is Facility's Phone: <br /> W, 18c_Signature of Alternate Facility(or Generator) Month Day II Ys <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3 4. <br /> c --T, <br /> 20.Designated.Facility Owner or Operator:Certifi ation of receipt of hazard s materials covered by the manifest except as noted in Item 18a P p <br /> Printed/Typed Name ,n Signature Mont <br />