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Please print or type. Form Approved.OM No,2050.0039 <br /> UNIFORM HAZARDOUS 11•Generator lD Number 2.P e t of 3.Emergency Response Phone 4.M ife�s}t T61kiiinng Humber /�` <br /> WASTE MANIFEST C .�� G V G 4 2 0 V J J <br /> 5.Generato>'s Name and Mailing Address �t�},` en rata,' SiEe�Addre s T di0eren n mailing address] <br /> Generators Phone: <br /> 6.Transporler 1 Company Name U.S.EPA ID Number <br /> CLEANTECH ENVIROMEWAL CALOOD399638 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEANTECH ENVIROMENTAL U.S.EPA iD Number <br /> 5820 MARTIN RD CALOOQ3V452 <br /> IRWINDALE,CA 91705 USA <br /> Facility's Phone:626-812-7200 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,tD Number, 10.Containers 11,Total 12.unit 13.Waste Codes <br /> HM and Packing Group(if any)] No. Type quantity vvt.Nol. <br /> 1• NON-RCRA HAZARDOUS WASTE SOLID(ASSORSENTIPAPER FILTEF P 352 <br /> o MEDIA) ��-} � •�� <br /> LI <br /> 2 2. NOW-9r.RA.L:jAzARnaijsWAS1ESO1 in(OILY SOLIDWASMAJISED DM P 352 <br /> w <br /> C7 �tSj- <br /> 3. <br /> 4. <br /> L <br /> 14.Special Handling Instructions an 'I nal Information <br /> 9E11 PROFILE# F!16 rok USE GLOVES AND GOGGLES TANKER# L—!L <br /> (PAPER FILTERS) tFILTtW <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL AS REGISTRANT:INFOTRAC 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 Iabelediplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the atlaehed EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quanttty generator)is true. <br /> GeneratAr'or,,O, <br /> 's PrintedfTyped Na e Signature Month Day Year <br /> / [c <br /> J 16.intematiorial Ship isF] r <br /> F Impart to U.S. ❑Export from U.S. Port of entrylexiC <br /> ? Transporter signature(for exports only,): Date leaving U.S.: <br /> W 17.Tran sporlerAcknowledgment of Receipt of Materials <br /> a Transporter ntedrT ped Name Signature 4 Month Day Year <br /> 0 <br /> CL r r� <br /> 2 Transporter 2 PrintedfTyped Nae Signature Month Day Yea* <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue <br /> yp Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facitily(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Altemata Facility(or Generator) Month Day Year <br /> a <br /> x <br /> y19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 i � �`L{ 2 3. 4. <br /> 20.Designated Facility Owner or Operator: ertification of receipt of hTrdous materials covered by the manifest except as ed in Item 18a <br /> PrintedlTyped Name Signature Month Day Y r <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYST M <br />