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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, Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number pp <br /> WASTE MANIFEST Ci-bAL000/4005;"_s0 Q Y..@-3'- —2/368 015895832 NJJ K <br /> 6. Generators Name and Mailing Address Generators Site Address (fif different than mailing address) <br /> N ARK UNIFORN4 AND CAPEER APPA 2EL LL+I <br /> 7879 LONGE ST <br /> TOCKTOI`3v CA 25200 <br /> GeneratorsPhona:200` +'+ <br /> 6. Transporter 1 Company Name U.S. EPA IO Number A &%S' <br /> PHILIP WEST INDUSTRIAL SERVICES 12�ARW4 7021 <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> r�E�Ehns ��m t+'ti>0.STEtNrs•�i,�a�ErnE�1`� 1Ne i��Ett�s�f���4 � ; <br /> 35251 OLD SKYLINE ROAD <br /> KETT ii CA 93239 <br /> Facility's Phone: 800—',!i2-2904 <br /> go. 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 Quandly WfNoI. <br /> 1. <br /> 3. <br /> W i I <br /> rrI u <br /> 4. <br /> 14. Special Handling Instructions andAdditionai Information <br /> PROR LE # CA5108852 <br /> 15, GENERATOR'SfOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described aboveby 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 EPAAcknowiedgment of Consent. <br /> I certifytitatthe waste minimization statement ldentifi din 40 CFR 262.27(a) Cif I am a large quantity generator) or (b) (if] am a small quantity generator) is true. <br /> GeneratorslOHerars Prince yped Na Signature Month Day Year <br /> J 16. Intemationa hlpmens <br /> i-- ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> z Transporter signature (Imexports only): Date leaving U.S.: <br /> W17. TransporterAcknowledgmenlofReceipt of Materials <br /> Transporter l Pnmed7fyped Name Signature Month Day Year <br /> Dam 14 <br /> QTransporter 2 Veered/ typed Name - Signature Month Day Year <br /> h <br /> 18, Discrepancy <br /> 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Fuli Rejection <br /> Manifest Reference Number: <br /> 181h. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> Faclifys Phone: <br /> W 18c. Signature ofAlternate Facility (or Generator) Month Day Year <br /> z <br /> 199. Hazardous Waste Report Management M mod Codes (i.e., codes for hazardouswaste treatment, disposal, and recycling systems) <br /> 1rJ1 2. 3. 4. <br /> a <br /> 20. Designated Fa ty Owner Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item lea <br /> PrintedllypedN e ' Signature Mo�pay Year <br /> 47/ ` <br /> EPA Form 8700-22 (Rev. 3-06) evious editions are obsolete. DESI HATED FACBLIITV TO DESTINATION STATE OF RE011 <br />