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P <br /> Please print a:_r, <br /> Form Al OMB No.2050-0039 <br /> to :UN:1F0RmK6ZARDl I.Generator lD NumberASTE MANIFEST 2.Page 1 of 3.Emergenq Response Phone 4.Manlfesl Tracking Number <br /> 5.Generators Name and Maili 1 efl0-535-5053-INFOTRAC <br /> ng Address <br />,q `[_,' L} ` r$ '� A ti f a Generators Site Address(if d{Rerenl than mailing address) <br /> Generators L ]• ' ' I /T r rI , tr� <br /> done: s- <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ti <br /> CLEANTECH ENVIRONMENTAL INC. CAL000368136 <br /> 7,Transporter 2 Company tfame U.S.EPA i0 Numher <br /> r <br /> 8_Designated Faciliry Name and Site Address U.S.EPA ID Number <br /> CLEANTECH ENVIRONMENTAL INC. CAL000330453 <br /> 5820 MARTIN ROAD <br /> IRWINDALE,CA 91706 USA <br /> Facilitys Phone: 626-812-7200 <br /> 9a. 9b.U.S.DOT Description{rnGuding Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11_Total 12.Unit <br /> 13 Waste Codes <br /> HM and Paolring Group tit any)) No. Type quantity WINoI. <br /> 1• NON-RCRA HAZARDOUS WASTE SOLID (USED ABSORBENT) DM P 352 <br /> ra � <br /> w 2. NON-RCRA HAZARDOUS WASTE SOLID (ABSORSENTIPAPER DM P 352 <br /> ca FILTER MEDIA) <br /> 3. NON-RCRA HAZARDOUS WASTE SOLID (OILY SOLID WASTEIUSED DM P 352 <br /> METAL OIL FILTERS) <br /> 4_ <br /> 14-Special Handlm Instructions and Additional Information <br /> 961) PRUILE# 962)PROFILE# USE GLOVES AND GOGGLES <br /> (ABSORBENT) (PAPER FILTER) 9B3) (METAL FILTERS) <br /> CALLER MUST IDENTIFY CLEANTECH ENVIRONMENTAL A5 REGISTRANT: INFOTRAC 800-535-5053 <br /> 15, GEN£RATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are cfassif ed.packaged, <br /> marked and iabeledlplacarded,and are in all respects in proper oonditon for transport according to appi cal international and national governmental regurations.If export shipment and I am the Primary <br /> Exporter,I oertity that the corttents of this c❑nsignmaal conform to the terms of the attached EPAAcknewfed9ment of Consent_ <br /> I certify that The waste minimization statement identiffed in 40 Cl 262.27{a)(ii I am a large quantity generator)❑r(b)(if I am a small quantity generator)is hue. <br /> GeneratoeslOffisWs PrinSedlTyped Name Signature Month Day Year <br /> l r <br /> J" <br /> _1 16.International Shipments import to U.S. ❑Export from U.S. Part of enirylexit: <br /> Ill Dale leaving U.S.: <br /> Transporter signature(for expods only): <br /> oG 17.Transporter Acknowledgment of Receipt of Materials <br /> tW- Transporter I PantedlTyped Name Signature / . / <br /> Month Day Year <br /> Z Transporter2 PrintedlTyf�Name Signature_ Month Day Year <br /> r � <br /> 1$.Discrepancy <br /> 18a.Discrepancy Indication Space Ouantlry ❑Type ❑Resitlue ❑Partial Re)ection ❑FuN Rejection <br /> C Manifest Reference Number. <br /> U.5.EPA ID Number <br /> I el Alternate Fadlfor Generator) <br /> U <br /> rat FadI llls Phone: Month Day Year <br /> 1 ac.Signature of Allemate Facility(or Generator) <br /> UJI <br /> x rt Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 19.Hazardous Waste Repo a 2. <br /> W 1• <br /> 20.Designated Facility Owner or Operat°r.Ce tif'calron of receipt of hazardous materials covered by the manifest'excepi as noted in Ill 18a Month Day Year <br /> ure <br /> Pr niedlTyped Name <br /> revious editions are obSDlete. <br /> GENERATOR'S INITIAL COPY <br /> EPA Form 8100-22(Rev.12 171 P <br /> { <br />