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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) . ' Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. rageof 3. Emergency Response Phone 4. Manifest Tracking Number p qqp��// WASTE MANIFEST Qe RL FJf� 6�v 5 82n_33 —2�€i8 015895849 JJ K j 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) APANIARK LIN FORM AND CAREER APPAREL LLC 1l LONGE vT j IfTOCKTONe dA 95200 Generators Phone.-209-2340105 A&�� U.S. EPA ID Numbe Ch66 AV 6. Transported Company Name � c.�ss PHILIP 'WEST INDUSTRIAL SERVICES U.S. EPA ID Number 7, Transporter 2 Company Name B. Designated Facility Name and SileAddress U.S. EPA ID Number CHEMICAL V1?ASTE419RWEMEN € € N 625 -1 0L D SKYUNE WAD KETILEPI.N !, CA 933299 Facility's Phone: 8010+-222-2904 go. 91g. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tolal 12. Unit 13. Waste Codes HM and Packing Group (9 any)) No. Type Quantity WLA7ol. 1. 8 o NDN Re;SRA HAZI;RIDOI IS ;WASTE, StjL @E3 t CI =_ 3_4@1__ F a gp t � k I s 4 4. y 14. Special Handling Instructions and Additional Information RRDFI LE O CA008852 J' x/262 */� - 15. GENERATOR'SIOFFEROR'SCERTIFIC®ATION: Iherehy declare thatthe contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and Iabeled(placarded, and are in all respects in propercondilion for transport according to applicable international and national governmental regulations. If export shipment and i am the Primary Exporter, I codify thatthe contents of this consignment coidorm to the terms of the attached EPAAcknowledgment of Consent. I cedify that the waste minimization st11 atement identified in 40 CFR 262.27(a) Or I am a large quantity generator) or (b) (if I am a small quantity generator) is me. Generators/Otte ors Pri ed Signature Month Day Year LJL 16. oma can, Shipman ts ❑ Export from U.S. . Pod of entry/exit: F, ❑ pod to U.S. Transporter signature (for exports only): Date leaving U.S.; W17. Transporter Acknowledgment of Recelpl of Materials Transport r riled yped Name Signaler Month Day Year M Transporter Printed/Fy ed Name Signature Month Day Year r 18.Discrepancy the. Discrepancy Indication Space ElQuantity []Type ❑.Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 181g. Alternate Facility (or Generator) - U.S. EPA ID Number J U Facilily's Phone: w 18c. Signature Month Day Year ofAltemate Facility (orGenerator) Q z 19. Hazardous Waste Report Man agement Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) 3, 4, 20 Designated Facility Ow r Operator: Codification of receipt of he rdous mat nate covered by the manifest except as need in Item 18a Mo Day Year Printe lfryped Name Signature EPA Form 8700-22 (Rev, - ) roving di(ionsamobso te. DiSSOUNAULDRACO . 7 DDE TiO€ UATIO9a8 IF REQUIRE )