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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 20500039 <br /> UNIFORM HAZARDOUS 1. GeneratorlD Number 2. Page i of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CALOJ`104059 V I 3s -.634-2453 014789131 JJ K <br /> 5. Generators Name and Mailing Address Generators Site Address (it different than mailing address) <br /> A,R�CPeSARK v . <br /> 7579 S. LONGE ST <br /> 5T:CKTON, .GA 25e35 <br /> Generators Phone:209-234.010.+ <br /> 6. Transpoder l Company Name U.S. EPA ID Number <br /> PHILIP WEST INDUSTPRL SERVICES CAR0001'r7527 <br /> 7. Transporter Company Name U.S. EPA ID Number '.. <br /> 8. Designated Facility Name and Site Address US, EPA ID Number <br /> 1ntASTE P�4A4VtiEMEIUT i=:'TiLEMAN 'LANDFILL nkTCOkS45117 '. <br /> X5251 OLD SKYLINE ROAD <br /> KETTLEP AR, CA 93239 <br /> Facility's Phone: 3 � 296A <br /> ga 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 any)) No. Type Quantity WLNoI. <br /> 1. NON RCRA HAZARDOUS NAIASTE, SOLID 001 CM 15 491 1. <br /> 0 ( LAIJNDRY S UDO;c} - .._„_., I •� - - <br /> Z 2. <br /> I <br /> 3. <br /> 14. Special Handling Instructions and Additional Information <br /> UNE1 : PROFILE: CA505U52 LAUNDRY SLUDGE ERL4171 y�j'YI.�Y 01 q <br /> YEAR PRO I ECTI4'E CLOTHING AND EYEA'EAR, <br /> 15, GENERATOWSIOPFEROIVS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shlpping name, and are classified, packaged, <br /> marked and labelediplacarded, 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 '.. <br /> Exporter, I certify that the contents of ibis consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I codify that the waste minimization statement identified in 40 CFR 262.27(a) (If I am a large quantity generator) o 4(b) (if I am a small quantity generator) is true. . <br /> €n@rotor Offences tinted - ped Name rL Signal Ce l E, Moar <br /> Month Day Ye <br /> r 16. International Shipments <br /> e ❑ Impertto U.S. ❑ Export from U \II� L <br /> ,S, od ofentrylexit: <br /> Transpodersignatum (for exports only): Date leaving U.S,: <br /> W 17. TranspoderAcknowledgment of Receipt of Materials <br /> erl Printed7ryped Name Signature Month Day Year <br /> 0 �icr v ITZ6 <br /> a Transporter2 Pd edfryped Name Sign Month Day Year <br /> rY <br /> h <br /> 18. Discrepancy <br /> 18X. Discrepancy indication Space ❑ Postal Rejection jectton <br /> ❑ Quantity ❑Type ❑ Residue 1 El Re <br /> Manifest Reference Number: <br /> Diu. Alternate Facility (ar Generator) U.S. EPA ID Number '.. <br /> J <br /> U <br /> Facility+s Phone: <br /> ae 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1. 2. <br /> 20. Designated Facility Owner or Operator: Codification of receipt of hazardous materials covered by the manifest except as noted in Item IBX <br /> Piintedlryped Name Signature Month Day Year <br /> 0 I at I 1. <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED [FACILITY TO DESTINATION STATE (IF REQUIRED) <br />