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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 019 7 4 2 614 JJ K 5.Generator's Name and Mailing Addr ry r_ e S;lq Address(if different than mailing address) Z. MA J Generator's Phone.- 6. hone:6.Transporter 1 Company Name U.S.EPA ID Number CLEAf.ITEr�H ENVRQNr� l? 1^i 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number CLE.AftlTEr,H Ef�:'�11R�=I(�1htENT:A:L!i'dC =8211 NiARTIN PC AD CHL00033.045.3 iRVVINDALE,CA x1706 USA Facility's Phone: 626-812-7200 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 1. No. Type Quantity Wt.Nol. 13.Waste Codes O ' _. --- _ ._ . .. iR F164E LU W Z 2. LU I,J1DN-FCri:A tiAZA.RD0 IS VVA.STE 0L!D(`1 L SLID VVA.STET I SED Crtyt -- F frtETP:L�DIL F!LTFf?.S} 3. -rte.. --` N� ,i ._J'14= 21 Handling Instructions and Additional Information 92E511PROF E —=+ec�ir^- ;i l- 11'_ t 7`r ?a _<__n_ k.• 7t 'E�_L� ES ND � _LE_= T NKEF.. U'AETAL F!LTE~•S} rI ca�Cr�aF;. ,r;rAFtlT/'; -- CALLER MUST IDENT!F`•r CLEANTECH ENVIF'_1VI DENTAL AS RE C_!.T RA,f%]T. Ifl!F0T R,A rte• Fj CiiD_:_,. 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, marked and labeled/placarded,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 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator 0 o s Printed a Name Signatur Month Day /Year J 16.International Shipments `� ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): t leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printedrryped Name Signata Month Day ar O CL ` /, ( )P � Transporter 2 Printed/Typed Name Signature Month Day Year F- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑ Type El Residue IJ Partial Rejection ❑Full Rejection Manifest Reference Number: � 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ U LL Facility's Phone: Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ In 1' 2.,tt \r U 3. {lam'Ivy � 4. 20.Designated Facility Owner or Operator: eriification of receipt of hazard s materials covered by the manifest except as noted in Item PrintedlTyped Name + Signature Month (�DaK Y r �MA,III 1!L.0, 71N�W I \ V V J EPA Form 8700-22(Rev.12-17) PrevioArfdifions are obsolete. DESIGAIATED FACILITY TO EPA's e-MANIFEST SYSTEM