Laserfiche WebLink
Please print or type. Form Approved. OMR No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4 .Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 4 . 0 6 5 9 5 ' 1 84�-3x4.2460 019 515111 J J <br /> " '0AUIgrs NaR,gn51M laijgg®dtU@ SERV10ES F Generator's Site Address (Hdifferent than mailing address) <br /> 7679 LONGE STREET <br /> STOCKTON CA 95 <br /> Generators Phone: 2 09 2 3 4 0 1 0 5 <br /> 6. Transoder 1 Company Name U.S. EPA ID Number <br /> PHILIP WEST INDUSTRIAL SERVICES C A R 0 0 0 2 6 9 5 4 6 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number '.. <br /> 8. De, Igp�gdEaci it @mC 3LdS e6ddr�5eltitC- KETTLEMAN HILLS U.S. EPA ID Number <br /> 35251 OLD SKYLINE ROAD <br /> 14ETTLEMAN CITY CA 93239 <br /> Facility's Phone: 5W 3®fa-9711 - O A T 0 0 0 6 4 6 1 1 7 <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (ff any)) No. Type Quantity Wt.NuL 13. Waste Codes <br /> �, 1 ' NON RCRA HAZARDOUS WASTE. SOLID 491 <br /> O - - ®Q 2. <br /> 0 0 1 Cm Y <br /> w <br /> 3. <br /> 4. <br /> 4. 53b" �+"eb� d2ien ��mIg1h4BER 122 -1510- 0010- J0001 L Alt (a 1v55SC3`1 <br /> Vt4*37 9 0737 J0 <br /> 15. GENERATOR'SIOFPEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aal are classified, packaged, <br /> marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable intemalionaland national governmental regulations. if export shipment and I am the Pdmary '.. <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknovfiedgment of Consent. <br /> I codify that the waste minimization statement Mont8led in 40 CFR 262.27(x) (If I am a large quantity generator) or (b) (ifI am a small quantity generator) is true. <br /> GeneratorslOffemes 'ntedAyp e a Signature ,(�°' Month D`ay�' Year <br /> 16. Interna ona ipmenls <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> Transporter signature (for exports only): Dale leaving LLS.: <br /> w 17. TransporterAcknowledgment of Receiptof Materials <br /> Transporter 1 Printed7Fyped Na Signature Month Day Year <br /> O <br /> r1 _ <br /> TraWortar 2 Printedflyped Name Signature Month pay Year <br /> F- <br /> 18. Discrepancy <br /> lea. Discrepancy Indication Space ❑ Quantity ❑ Type yp 11 Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> raQ- Facility's Phone: <br /> w tOc. Signature ofAllernate Facility (or Generator) Month Day Year <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous wasle treatment, disposal, and recycling systems) <br /> 4. <br /> 20 Designated Facility Owner or Operator: Certification of receipt of hazardous malertals covered by the manifest except as acted in Item 18a , <br /> Printed6l'ype Name Signature Month Day Year <br /> EPA Form 700-22 (Rev. 12-17) Previous editlonsara obsolete. DESIGNATED FACILITY TO EPA's a"MANIFEST SYSTEM <br />