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Blease prifd or type. _ Form Approved.OMB No.2050-0039 <br /> UTAFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST � "� L 620023188 JJ K <br /> 5.Generator's Name and Mailing Add s bile Address(if different Than mailing address) <br /> FOLD°LABEL T OOT)EO. <br /> LINE.AFFIX TO RIGHT <br /> SIVE OF HAZARDOUS, <br /> w J MATERIAlBILLS SOTHAT <br /> Generators Phone: TAB STICKS OUi <br /> 6.Transporter 1 Company Name U.S.EPA ID Number LT18, 1°91'^.,°ow..0l, <br /> CLEANTECH ENVIROMENTAL CAL000399638 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> HERITAGE ENVIROMENTAL SERVICES LLC <br /> 284 EAST STOREY ROAD AZD081705402 <br /> COOLIDGE,AZ 85128 USA <br /> Facility's Phone:520-723-4167 <br /> 9a: 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11-Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WI.Nol. 13.Waste Codes <br /> X 1" RCS,UN1950,WASTE AEROSOLS,FLAMMABLE,n.c.s.,2.1 (PAINT, DM. P D003 331 <br /> 0 LUBRICANTS),(D001),ERG#126 Q11 '7D <br /> Z 2. <br /> w <br /> r9 <br /> 3. <br /> I <br /> 4. <br /> I <br /> 14.Special Handling Instructions and ydd" I3(q lig0 <br /> 01)PROFILE# !I II��IV)� USE GLOVES AND GOGGLES TRUCK# <br /> (AEROSOLS) <br /> CALLER FAUST IDENTIFY CLEANTECH ENVIROMENTAL AS REGISTRANT: INFO TRAC 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 applicablo international and national governmental 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 EPAAcknoWedgmenl of Consent. <br /> I certif the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity ge Ofl Eyn a small quantity generator)is true. <br /> d ,Signature _ Month D y Year <br /> ener orslOtierors note d Name <br /> -"j 16.Inlematon I Shipment LL <br /> ' 1 <br /> zImport to U.S. ❑Export from U.S. of enlrylexd: <br /> Transporter signature(for ex orfs 1Fly). Date leaving U.S.: <br /> X 17.TransporterAcknowledgmenl of Receipt of Materials <br /> w <br /> Transporter 1 Pr ntedrfyped NIme Signature Month Da Ycar L�S2 W I <br /> O <br /> CL - <br /> zTransporter 2 Pdrlfedrryped Name Signature Month D nr <br /> C 2 7J <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Allemate Facility(or Generator) <br /> J U.S.EPA ID Number <br /> C), I <br /> iQ Facility's Phone: <br /> W 18c•Signature of Allemate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.o.,codes for hazardous waste treatment,disaosal,and recycling systems) <br /> LU <br /> 1. 4..I,, <br /> ' 3. 4. <br /> 20. osignaled Facility Owner or Operator:Certification of recaipl of hazardous materials covered by the manifest except as nded in Item 18a <br /> Print ped Name <br /> s le Sig ure Month Day Year <br /> Q,4 r <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obso ale. DESIGNATED FACI ITY TO E}1R's e•MANIFEST SYS EM <br />