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Ploase print or type. (Form desionerf ihr irca nn u51c jwo—r+ kw k...... <br />1. G ara!or ID Number Form proved. OMB No. 2050.003: <br />t <br />EPA Form 8700-22 (Rev. 3.05) Previous edilions are cbsolete <br />GENERATOR'S INITIAL COPY <br />UNIFORM Hf17ARDOUS 2 Page 1 of 3. Emergenry Response Pr ono d. Manliest hacking Num er <br />1 <br />` <br />wasreMameand G A Q a 3 3 3 8 :� t3 008481620 JJK <br />Generator's Name � �� 4� g`� ��� <br />Mad'ng <br />and Address <br />&WBU+S ENG4NE & TFilVVFil ISg0N Generators Site Address (d different than mailing address) + <br />ta11 E CHURCH STREC—T � <br />STOC:KTON C A 96206 <br />Genera"" Phone: q <br />E. Transporter 1 Company Name <br />FP -M()UW LNVIRONMENT L SERVICES INi : MANS U.S EPA ID Number <br />7. Tra*orfer 2 Company Nems t 0 0 i 7 <br />U.S kPA ID Number <br />ENV ENVIRONAAkNi At INUE, NA110NAt. <br />8. Dbsignated Faality Name and Site Address i. A fi Q () f7 1 % fI J i; � <br />US ECOLOGY INC; U.S- EPA ID Number <br />HWY Sits TIMI 5 OP C:Y !C ArRLS <br />IStATTY NV 8gow <br />FadCs Phone: - 'S <br />9b. U.S. Dor N V 7 :i 3 {) ! t7 Q d d <br />9a. Description (indumng Proper Shipping Name, Hazard Class, ID Number. <br />1U. ContaneB <br />NM and Packtlg Group (if any)) 11 Total 12. Unit <br />1 No Typo G�uanbty yyt Nd 13 Waste Codes <br />o <br />W)4R(-NAHAfAF2C�i.7(JS WASTL Llc;tUlf)S (OIL Y SI.C#[?C�E I <br />:143 <br />z <br />z. <br />W <br />0 <br />3. <br />d. <br />14. Special Handling IrMniM�rs and hlonal r*rmabon ! <br />Oy <br />90tip E WWI 17 ! <br />fL1NI)1 FR3 0 tits 4011tt TRAINF], AND 11SU PF14. <br />15. GENERATOR'BJDFFEROR'S CERTIFICATION: I hereby declare that the contents this <br />of consignment are fuly and aoMiVely described above by the proper shipping name, and are classrled, patdoged, <br />markod and fabele4l.;Parded, and are io all raspocts in propor condition for transport du,Ardinxg M applicable intarrw.Kmaland national govemmernal regulations- If export shpme 4 and I am the Primary <br />Exporter, I oar;jy that the contarris of tins cor> gnment conform to the terms of the <br />attached EPA Acknowledgment of Consent. <br />I certify that Ute waste minimization statement Identified In 40 CFR 262.27(a) (if I am a large quantify gerterator) of (b) (if I am a small quantity generator) is rnrn. <br />GeneratorsJOiferor'sPrintedrfypedName Signalure Month Day Year <br />—r <br />!— <br />6.ImematlenalShipments <br />❑ tmport to U.S, ❑ <br />Z <br />Export from U.S. Port o1 antryietm: _ O <br />Transpartor signature (for exports onlv)" J <br />W <br />Date leaving U -S.: <br />17. TranSM"jAdmAJ&dgmer4of Reco pt of M tedals <br />02 <br />Transportar 1 Printedlfyped Name SlgnaturqLMonth Day Year <br />a <br />Q7ranspaiar <br />2 PrintaC ame <br />Signature Month Day Year <br />Discrepancy <br />18a. Discrepancy Indleabon Space <br />❑ Quantity ❑type ❑Residue Partial Rejection ❑Fu!IRejectlon <br />Man Nast Reference Number. <br />18b. Ntemale Fedkry (or Generator) U.S. EPA ID Number <br />r <br />V <br />L <br />Facility's Phone: <br />W <br />r <br />18C. Signalure tamale Fadiry (or Gen8mr) M uttll Day Year <br />N19 <br />Hazardous Waste Rapod Manago"M Method Codes (I e, codes for hazardous waste imabrtera, disposal, am rcy Ing systems) <br />C <br />26. Designated Fadl.ry Owner or Operator: Corbflcatlon of recelpl of hazardovt matenals covered by the manifest except as rded in Item 18a <br />NntedlTy name Slpn3lura Month 5ay ear <br />1 1 I <br />EPA Form 8700-22 (Rev. 3.05) Previous edilions are cbsolete <br />GENERATOR'S INITIAL COPY <br />