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Please print or type, (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Pa a 1 of 3, Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAL1Of3€ 406595 8144`33dd 2468 015 895799 JJ K <br /> 5. Generators Name and Mailing Address Generators SileAddress (ff different than mailing address) <br /> AP.o~. tK UNIFORM AND CAREER APPAREL LLC <br /> S K ON, COE A 85205 <br /> Generators Phone,2t79-284-0105 <br /> 6, Transporter l Company Name US. EPA ID Number <br /> PHILIP WEST INCILISTRIAL SERVICES CAR000177527 <br /> 7. Transporter 2Company Name U.S. EPA ID Number L . <br /> 8. Designated Facility Name and SileAddressU.S. EPA ID Number <br /> CHEMICAL WASTE Pv1AIj11�.°SEMERIT INC U.S. <br /> 35251 OLD SKYLINE ROAD <br /> KE`I i LEMIAN, CA 93239 <br /> Facility's Phone: 800-222-2964 '... <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, V. Containers 11. Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No, Type Quantity WLlvol. '.. <br /> 1 ` <br /> o NON RCRA HAZARDOUS WASTE, SOLID 1 Cd t 6 421 40111 <br /> �___� <br /> 9 <br /> 3. t <br /> 41 <br /> it. Special Handling Instructions andAddificnal Information fS <br /> PROFILE 0 CA608852 <br /> 15, GENERATOWS/OFFEROWS 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 applicable 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 EPAAcknowledgment of Consent. <br /> I teddy that the waste minimization statement Identified in 48 CFR 262.27(a) (if I am a large quantity generator) or (b) (IfI am a small quantity generator) Is We. <br /> GeneratoM <br /> nted7fyped m Signature Month Day Year <br /> I <br /> \ � � �� Iv r � f6 <br /> .� 16. Internnts <br /> t— <br /> El import to U.S. V El Export from U.S. Portof .nhylexf. <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> ad17. Transporter Acknowledgment of Receipt of Materials <br /> 82 Transporte5l ped Sig re Day Year <br /> O JJ <br /> d <br /> QTransporter Pdnted/Typ dName Signa Month Day r ° <br /> rK <br /> r- <br /> 18. Discrepancy <br /> .� 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Par iai Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> uu Faciftys Phone: <br /> w <br /> I Be. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> z <br /> 0 19. Hazardous Waste Report Management Method Codes (Io., codes for hazardous waste treatment, disposal, and recyding systems)LIU ' <br /> ® i ' �� 2. - 3. - 4. <br /> 777 1 <br /> 26. Designated Facility Owner or perator. Codification of receipt of ha Nous materials covered by the manifest except as inn in Item 18a <br /> PrntedlTyped Name i S(gnature Mont D Ye <br /> 8 ` <br /> EPAForm8700-22 (Rev. 3-05) Previous editi s are obsolete. DESIGNATED FAO `8O DESTINATION STATE (IF REQUIRED) <br />