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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) y Farm Approved. OMB No. 2050-0039. <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page I of 3. Emergency Response Phone 4. ManifestTracking Number <br /> WASTE MANIFEST CAL€ LIL141 55595 / 841-33444.NS 015895881 JJ K <br /> T. Generators Name and MallingAddress Generator's SlteAddress lit difiereat than mailing address) <br /> A,RAMARK UNIFORM M*`s€? CAREER APPAREL LL c <br /> 7L 79 LONGE ST <br /> S�IOCKTON. CA 95200 <br /> Generators Phonp:209-234-171f75 <br /> 6. Transporter i Company Name U.S. EPAID Numbe <br /> P UP WFEST INDUSTRIAL SERVICES 0-025) �J <br /> 7. Transporter 2 Company Name U.S. EPAID Number '.. <br /> - 8. Designated Facility Name and Site Address p P-� RR,,44 ��''���vv� CC�� U.S. EPA ID Number rl <br /> CHE€vtlCAL `A;%S*TE [VIA4.�,AEGEIMIENT INC. S ATk�tll7ls4 f Or f <br /> 35251 OLD SKYLINE ROAD <br /> €4EMEMAN, CA 53231 <br /> Facility's Phone: E0&222-2904 <br /> ga. 9b. U.S. DOT Des olplion (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers11. Total 12. Unit 13. Waste Codes '.. <br /> HM and Packing Group (if any)) No; Type Quantity WtArol: <br /> 1. <br /> o NON'q RC FSA HAZARDOUS WASTE, SOLID / CM ® Y _ . c., s-49.1 <br /> 21 <br /> t <br /> 4. ppt <br /> ( I <br /> 14. Special Handling Instructions and Additional Information . Ie 0E <br /> PROFILE CA095+352 UC <br /> 15. GENERATOR'SIOFFERQWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name,and am classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for kansport according to applicable International and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, i cerfity that the contents of this consignment conform to the terms of the allached EPAAcknowledgment'of consent. <br /> I codify that the waste minimization statement idenfitied In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) If I am a small quantity generator) is true. <br /> Generetor OH Ys Pd its N e,� Signator/e , 7 Month Da Year <br /> —e 16. Intemaional Shipm nts <br /> T— import to U.S. ❑ Export from U.S. Part of enfrylexlC <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> w 17. TransporterAcknmdedgment of Receipt or Materials <br /> Tmnspo Ptariff, ed Name Sfgnalur ` Manih ,Day Year <br /> a GAT <br /> 2�. Transporter 2 Piftibeirryged Name Signature Month Day Year <br /> .p <br /> 18. Discrepancy <br /> 18a. Discrepancylndicagon Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Funnily (or Generator) U.S. EPA ID Number <br /> J <br /> CJ <br /> LL Facility's Phone: <br /> w 18c, Structure ofAttemata Facility (orGenerator) Month Day Year . <br /> Q <br /> Z <br /> ig. Hazardous Waste Report Management Method Codes I.e., redactor hazardous waste treatment, disposal, and recycling systems) <br /> . ..&\ 1 !;7 <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnal p d(dame Signature - Month Day, Year <br /> EPA Form 9100:22 (Rev. 3-05) Previous editions are obsolete. DESIGNATE© FACILITY TO DESTII99T ION STATE (IF REQUIREC4 <br />