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Please print or type.(Form designed for use on elite(12 pi(ch)typewriter.) Form Approved.OMB No.2054-0039 f UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone =95575 g Number WASTE MANIFEST (l V u I,. c x1 JJ K 5,Generator's Name and Mailing Address Generators Sits Address(if different than mailing address) 4AZA t Generatdr's Phone: `-;L AO 8.Transpgf[er 1 Company NameCLEANTECH EM'tR�N� TAL U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address �ieRITAGI•E!"()Nkr1 IgTAL SEI;it%..ACFS,`LLC U.S.EPA ID Number 284 EAST STOREY ROAD CtJC]l.lli AZ 85128 IDSA Facility's Phone: 20-72 -4187 9a. 9b.U.S.OCT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. 0 1' RQ� LW1950,WASTE AEROSOLS,FLAhMMA9L.E,n.4.a., 2 1,(RANT, P D001 331 LUBRICANTS),(DOO1),ERG*126 w Z 2. - Lu U) 3. 4. 1- -F- 1 14,Special Handling Instructions and Additional infoafign 901 F-RQFK-E* b ' t1SE 0L 0t&-5 Ali GIOGGI ES Tli � ��ST IDENTIFY CLEANTECH E"ONMENTAL AS REG119T: WFOTRAC 80"35-6053 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and.accurately described above by the proper sNippiag name,and are classified,packaged, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.271(if I am a large quantity generator)or(b)(if i am a small quantity generator)is true. Generator'sl0fferor's Printed/Typed Name Signature Month Day Yeaf 19?. 1,/ J 116.International Shipments i-- ❑Import to U.S. ❑Export from U.S. Port of entrylexit. z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year Transporter 2 Primed Typed Name signature Month Day Year - 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number; 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J U LL Facility's Phone: W I9c.Signature of Alternate Facility(or Generator) Month Day Year a z r, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 2. 3. 4. 4 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name �-; Signature � Month LeNDay Year r " L EPAForIn7pi}22{Rev.3 05j Previouseditions are obsolete. DESIGNATED FACILITY TO GENERATOR