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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. Pal 10118 1 of 3. Emergency Response Phone 4. Manifest Tracking Number '.. <br /> WASTE MANIFEST CA.L0004055$u f' 015895866 JJ <br /> -6. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br /> AP 2/aRK UNIFORM AND CAREER APPAREL LLC <br /> 7079 LONGE S <br /> 8TOCFK`TON, CA 95200 <br /> Gendafots Phone:200°234-0105 <br /> 6. Tramporter 1 Company Name U.S. EPA ID Number R0492,116954ff <br /> PHILIP WESTINDUS'TRIA! SERVICES :.nrtrtnn,-��a <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designaled Facility Name and Site Address U.S. EPA ID Number <br /> CHEMICAL AWASTE MANAGEMENT INC CAT00004611 '17 <br /> 35259 OLID SrLINE RCA4 <br /> KETTLES I, Cry 93239 <br /> Facility`s Phone: 906_222-29104 <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,(ifany)f. F No. Type Quantity WI,Nol. <br /> o <br /> NON RCRAHAZARIDOUS)A'ASTE, SOLIDl CM Y [ 491_ <br /> ® k t <br /> M 2. vp <br /> _.. -._ <br /> 3. <br /> kf <br /> 4. <br /> 14. Special Handling Instructions andAddlllonal Information <br /> PROFILE 0 CAA008852 <br /> fA214 'SlIv/40 ° a 494 0 <br /> 15. GENERATORS/OFFEROR`S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershlpping 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 certify (hat the %mate minimization statement identified in 40 CFR 262,27(a) (if l am a large quantity generator) or 0) (if I am a small quantity gen ralor) is true. <br /> Generatots/Offerors '"r pod Non(J Signaler Month Day Yeae, S <br /> �oeeJJ <br /> J 16. International Shipments <br /> 1 <br /> i— <br /> El import to U.S. ❑ Export from U.S. Port of entry/exit: 3 <br /> Transpodersignature (for exports only): Date leaving U.S.: <br /> w17. TransporterAcknowledgment of Receipt of Materials j <br /> Trans Printed/ryped Name Signal Month Day Year <br /> o <br /> 1 <br /> QTranspreAr2 Printed/ Iy ed Name - SimartareiF Month Day Year <br /> a' I <br /> 18, Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> Facility's Phone: <br /> 18D. Signature ofAllemate Facility (or Generator) Month Day Year <br /> z <br /> y10. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1. / 2. 3. 4. <br /> ) <br /> 20. Designated.Facilily Owner or Operator: Codification of receipt 0azardous materials covered by the manifest except as noted in Item Ise ? <br /> Pdwedfryped Na Signature Mdnt Y <br /> i <br /> EPA Form 8700-22 5) P v&us editions are(onallete. DESIGNATED riAciLhirylo DESTINATION STATE (BF REQUIRED) <br /> i <br /> 1 <br />