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Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Energetic Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST L D ® ® $ O 5 6 L144-3��-24s� 019515103 JJ K <br /> 5. GeaefAlals Name,gnd M la IIna.AdATSERUICES Generatots SileAddress (if different than mailing address) <br /> 7679 LONGE STREET <br /> SS TOCKTON CA 55206 <br /> Generator's Phone: 2 09 2 3 4 - 0 9 0 5 <br /> 6. TransoAct1 Campan Name U.S. EPA IDN rather <br /> PIL IP WEST INDUSTRIAL SERVICES C A � 0 0 0 2 6 9 5 4 0 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. DeslnnatedFaClllty NdNe d_Site9ddresslNG- KET LEMAN HILLS U.S. EPA ID Number <br /> 35251 OLD SKYLINE ROAD <br /> KETTLEMAN CITY CA 93239 <br /> Facility's Phone: 5559 386-5711 C A T 0 0 0 6 4 6 1 1 '7 <br /> im 9th. 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 (if any)) - - No. Type Quantity WI.A7ol. <br /> 1. NON RCRA HAZARDOUS WASTE, SOLID FO-- <br /> 491 <br /> 0 <br /> 0 0 1 CM Y <br /> us 2' <br /> 0 <br /> 3. <br /> 4. <br /> 14. 3paV1"1.Lr7f;nslmrAli�nts} rdd�i ionafgrn�YUP$ER 12d- �51 Q- 0411 U-r7'OGLi� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declare (hat the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged, <br /> marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable interna8onaland national governmental regulations. It export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment contain to be terms of the attached EPAAcknowledgment of Consent. <br /> I codify that the waste minimization %rt Idengfied in 40 CFR 262.27(a) (if I am a large quantity generator) at (b) (ifI am a small quantity ge true. <br /> Generatoea/OHerot ' to ed Na Signature Month Day Year <br /> 18, International Shipments . <br /> F- ❑ Import to U.S, ❑ Elipodfrom U.S. Portofentry/exit: <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TransporlerAcknowledgment of Receipt of Materials <br /> Tempo Printed/Fyped Name Signature Month Day Year <br /> o A / / <br /> 0 <br /> QTranspoi r 2 Prinled7fyed Name Signature Month Day Year <br /> F <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space ❑ Quantic ❑T a '.. <br /> Quantity yp ❑ Residue ❑ Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> r}- 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> ua- Facility's Phone: '.. <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.a,, codes for hazardous waste backrenL disposal, and recycling systems) <br /> 1. 2. 3. 4. <br /> M. Deslgnated Facility Owner or Operator. Codification of receipt of h arises materials covered by the manifest except as noted in Item 18a <br /> PriNedlTyped Name SlgnaNreMoplly Yqa ',,..... <br /> EPA Form 8700-22 (Rev, 12-17) Previous loons are obsolete. DESIGNATED FACILITY TO EPA's e•MANIIFIFIEST SYSTEM '.. <br /> a <br />