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Pleaseprintortype. Form Approved. OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS i. Generator ID Number2. Page 1 of 3. Emergency Response Phone 4. ManifestTrackingJJ KNumber pp pg <br /> WASTE MANIFEST G A L 0 0 0 40 <br /> 1 3�4•2019515109 <br /> 5. lea l is m dM Iy ijgg,Addre SERVICES Genermofs Site Address (if different (ban mailing address) <br /> 7679LONOWSUEET <br /> STOCKTON CA MM <br /> Generators Phone: 2 0 9 2 3 4 0 1 0 5 <br /> 6. Transotter 1 Company Name - U.S. EPA ID Number <br /> PPILIP WEST INDUSTRIAL SERVICES C A R 0 0 02 6 9 5 4 S <br /> 7. Tmnsporter2 Company Name - 4S, EPA ID Number <br /> B. Des-ynate�d F�acili Na a yndE5iMte0AdNdreTr INC, KE, �MAN HILL U.S, EPA ID Number <br /> 35251 OLD SKYLINE ROA <br /> KETTLEMAN CITY CA 93239 <br /> Facility's Phone: 30n9711 ® ® 1 <br /> go, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12, Unit '.. <br /> HM and Packing Group (if any)) NO, Type Quantity W1.11101. 13. Waste Codes <br /> 1• NOMRCRARAZARDWSMSTE. SOLID /� 491 <br /> 9 0 1 SRA Y <br /> 2. <br /> c� <br /> 3. <br /> 4. <br /> JIM <br /> 15. GENERATOWSIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeledlplacarded, and are tri all respects In proper condition frrtranspod according to applicable intemakonaland 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 ofthe attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (IN am a small quantity generator) is two. ' <br /> Generators/Offer Pr tedfry a SlgnaWre Month Day Year <br /> 16. International Shipments <br /> i— ❑ Import to U.S. ❑ Export from U.S. Port ofen(rylexil: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> W 17. TranspoderAcknowledgment of Receipt of Materials " <br /> Trans r 1do d7T ed Name Signa Month S Day Year <br /> a i <br /> Transport r2 PrintedRy ed Name Signature Month Day. Year <br /> !I <br /> 10. Discrepancy <br /> 18a. Discrepancy Indication Space <br /> ❑ Quantity []Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> r 106. Alternate Facility (or Generator) U.S. EPAIDNumber <br /> J <br /> U <br /> Facilitys Phone: <br /> 18c. Signature ofAllemate Facility (or Generator) - Month Day . Year <br /> y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 2. 3. 4. <br /> 20. Designated Facility Owner or Operator: Codification of receipt of h rdous 7terials covered by the manifest except as noted in Item 18e <br /> PrintedfTyped Name , Signature Mo th Day year <br /> EPA Farm 8700-22 (Rev. 12-17) Previous edi ns are obsolete. DESIGNATE FACILiANIFEST SYSTEM <br /> i <br />