COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 20500039 UNIFORM HAZARDOUS 1, Generator ID Number 2. Page l of 3. Emergency Response Phone 4. Manifest Trucking Number pp ry p� WASTE MANIFEST CAL85i7� t75695 844-3344-2463 015895852 NJJ K 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) ARAIVIARK UNIFORM AND CAREER APPAREL LLC: 7670 LONGE ';T STOCKTON, CA 95200 Generators Phone:210M34"13105 6. Transporter 1 Company Name U.S. EPA ID Numb % PHILIP kACM T INDUS IRIA.L SERVICE 5c 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address U.S. EPA ID Number ir;FiEMICAL WASTEIVl,�1.4��EfJ(ENT INCU.S. 35251 OLD SKYLINE ROAD KE'P LERPM, CA 9323@ Facility's Phone: 800 222-2964 9a go. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13, Waste Codes HM and Packing Group (if any)) No. Type Quanfity WtNol. JX 1. 4 r NON RCPA HA=A,RDOLIS ' 0 - M 2. pp 3. I 4 } 4. f ( 14. Special Handling Instructions andAddilional Information PROFi LE # CACIDS852 15, GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully an accurately described above by the proper sh ping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemalionaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the temu of the attached EPAAcknoWedgment of Consent. I certify that the waste minlmizat_ion statement Identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if) am a small quantity generator) is true. Genemlors/Offeror rint ed �� ' Signature / Month Day Year / G J 16, International Shipments ❑ Impart to U.S. Ll Expert from U.S. Part of entry/exit: z Transporter signature (for exports only): Date leaving U.S.: W 17. TransporterAcknmvledgmentof Receipt of Materials i2 Transporter i Printed/Typed Name Sign m Month Day Year QTransporter-2 PdnledfFy dName Signature Month Day Yeffr r- 18. Discrepancy 18a. Discrepancy indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U LL Facilitys Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year 19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 . 2, 3. 4. 20. Designated Fadli Owneror Operator: Codification ofr ceipt of hazardous materials covered by the manifest except as noted In Item 18a PrintedRyped Name Signature Mo th Da Year EPA Form 9700-22 (Rev. 3-05) Preieditio sareobsolete. DES[IG ATED RPK ' a aTVTO DES11HAVON STATE (OF PEQUORED1