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v .. Form Approved, OMB No. 20500039 <br /> St print or type. (Form designed for use on elite (12-pitch) typewriter.) _ _ <br /> UNIFORM HAZARDOUS 1. Generator 11) Number 2. Pagel of 3. Emer91 31 Response Phone 4. Manifest Tracking NOmbe't " <br /> WASTE MANIFEST cAsD64655 014789133 JJ <br /> 5. Generators Name and Maiiing Address - Generator's one Address (ifdieerent than malling address) <br /> A,RAMARK <br /> 7E,79 S. LONGE ST <br /> SrOCKTOF4, CA Si <br /> Generatoiiiiiii�rs Phone:209-234-0705 U.S. EPA ID Number <br /> 6. Transpoder l Company Name <br /> . PHILIP uME,"-.T INDUSTRIAL SERMCES CA'R000177527 <br /> U.S. EPA ID Number <br /> 7. Transpoder2 Company Name <br /> B. Designated Facility Name and Site Address U.S. EPAID Number <br /> BASTE NIA€iIAC-EMENT KE TLEM1I1A(L L+IFJDFILL GAiL+L�45117 <br /> 35251 OLD SKYLINE ROAD <br /> uETTLEN+iAR, CA 93239 <br /> Fatuity's Phone: 690-V£ 29,5it <br /> o. 9b. U,S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12, Unit 13. Waste Codes <br /> HM and Packing Group (if ariQuantity WtNol. S <br /> No. Type <br /> 1• IVOFJ Ili FtieZ .RDOUS i+1rASTE, SOLID OU1 Gtv1 . 15 491 <br /> r ; <br /> ( LAUNDRY SLUDGE)2, <br /> LU <br /> 3 <br /> 3. <br /> r <br /> d <br /> s <br /> 4. <br /> i <br /> 14. Special Handling Instructions and Additional Information <br /> LINE1 : PROFILE: CA603852 LAUNDRY SLUDGE ERGM71 <br /> !+YEAR PROTECTIVE GLOT ING;G AND EYEVVi G <br /> f>6(;;�5604C41 qLIJ <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are way 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 applicable international and national governmental regulations. if export shipment and lam the Primary j <br /> Exporter, I cedlfy that the contents of this consignment contain to the terms of the attached EPAAcknowledgment of Consent. j <br /> 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 We. <br /> G rat slOff ors�t�d ped Name Signa , _ / Month Day Year <br /> v foil S` I <br /> dor <br /> 16.1nternational Shipments Import to U.S. ❑ Export from U.S. Pod of entry exit: <br /> Transporter signature (for exports only): Date leaving US.: <br /> W 17. TmnsporterAcknowledgment of Receipt of Materials <br /> Tran. spoiler i Pdntedflyped Name <br /> Signature Month Day Year <br /> Y IraE <br /> M Transpoder2 rintedif yped Name Signature Mon Day YearIX j <br /> � P 0I <br /> 1 a. Discrepancy <br /> 189. Discrepancy Indication Space ❑ Quantity [] Type El Residue ❑ Partial Rejection El Full Rejection <br /> i <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPAID Number <br /> � 3 <br /> U <br /> epi. Facility's Phone: Month Day Year <br /> w18 <br /> a Slgneture ofAlternate Facility (or Generator) " <br /> Q <br /> Z <br /> 19, Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br /> 3 <br /> 4. <br /> . <br /> O 1 . 2' ) <br /> 20. Designated Facidy0wneror. Operator. Cedlfl agon of receipt of hazardous materials covered!to <br /> Pdnted/ryped Nam Mon ' Day Year <br /> i <br /> EPA Form 8700-22 (Rev. 3-05) Previou editions re obsolete. E d r® ®EST(Ii1A5`B®61➢ STATE (IF REQUIRED) <br /> i <br />