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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) rt Form Approved, OMB No. 2050-0039- UNIFORM HAZARDOUS 1. ( ewmrator ID Number 2. Page 1 of 3 Emergency Response Phone 4, Manifest Duelling Number gg gg�� WASTE MANIFEST CAL5Cd74175595 8441-3,"4-24659 015895888 aJJ K 5. Generatofs Name and Mailing Address Generators Site Addressof different than mulling address) '.. ,APAA4APK UNIFORM AND CAREER AdmPAREL LLG 7679 LONGE ST STOCKTON, CA 962015 Generators Phone:209-234`0.105 6, Transporter 1 Company Name U.S. EPA ID Numbe 'bd� PHILIP VVETINDUSfR,IAL SERVICES ., ' ' 7 7. Transporter 2 Company Name U.S, EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number CHEPh€ CAL ',{VASTE !b'dAfVl�,�;sEtVtENI' INC tiATCal39r��k3'i 17 35251 OLD SKYLINE ROAD KETTLEP:FAN, CA 93239 Fadwls; Phone; 80Dll,222-29l3A gra 91h. 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 Quantity Wt./Vol. L o NON RCRA HAZARDOUS 'WATE, SOLID CP✓t Y _ 49 � � G I Z 2. w ?. 3. I s 14. Special Handling Instructions and Additional Information PROFILE 0 C A50E352 15, GENERATOWSIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and alf classlfied, packaged, marked and labeled/placarded, and are in all respects in proper cond8lon for transport according to applicable international and national governmental regulations. if export shipment and I am the Primary Exporter, I ceruly that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I codify that the waste minimization statement Identified in 40 CFR 262.27(a) (if l am a large quantity generator) or (b) III am a small uanfitygenemtor) is two. Genemr�ger Prince Na _ SignatureYear f - Month Day r 16. International Shipments ❑ Import to U.S, LJ Export from U.S. - Pod of entrylexit: r � Transporter signature (for exports only): Date leaving U.S.: w 17.TransporterAcknoWiedgment of Recalpt of Materials � Tra rt Printedlty ed Name Signa Month Day Year r' / Tranefrofter2 immeaul ped Name Slgnatu Month Day Year K 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity 11 Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number 71 U Facility's Phone: " w 18c. Signature ofAlmnate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (l e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20. Designated Facility r or Operator: Certification of receipt of hazardo s materials covered by the manifest examples noted in He 18a Prints typed Name jnA Signature tenth Da Ye 1/� v EPA Form 870022 (Rev. 3-05) Previou ditions are obsolet DESIGNATED ITS TO DESTINATION STATE (OF REQUIRED)