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Please print or type. Form Approved.OMB No.2D5GM9 <br /> UNIFORM HAZARDOUS 1-.Gemra1ar tD NumbeT 2.Page 1 of 3.Emergency Response PhowMann�raac g N <br /> WASTE MANIFEST CAD;M M 2 1 4 x47-2857 2 1 O FLE <br /> 5.Generarofs Name and Mailing Address GeneraWfs Site Address(t ditrent than mailing address] <br /> Sutler Tracy Ct tnLlrity Hospital Sutler Tracy Community Hospital <br /> 1420 H TYLeYY B*11 1420 N Tracy SN-3 <br /> Tracy,.CA 953TSy Tracy, CA 9537G <br /> Generator's Phone:56,0-02D-M71 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Atlas En4ronmeMal Soltrtiorts CAL000433584 <br /> 7.Transporter 2 Company Name U.S.EEA ID Number <br /> 1�s "VM CSS czl �- � � off• <br /> B.Designated Faddy Name and SitaAddress U.S.EPA 10 Number <br /> US ECOLOGY NEVADA <br /> !- F!.1es Sc::1`t ci Beatty NV 3=10000 <br /> beauty, acv S�M3 <br /> Facility's Phone: 7 75� <br /> ga. ,9b.U.S.DDT DesaipSDn(indudirg Proper Shipping Name.Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 13.Waste Cedes <br /> HM and Paddrg Group(if arry)} No. Type OuanSty NRNoI. <br /> �Na,-�-RCRA FLuardaus Waste, VgiM(Bu&red Fcr;nwin) DF 1 � <br /> 85 P <br /> W 2NAM,Waste Hazarda�a waste,liquid,ma.s. (GHRO?JIILM, 135 ❑007 <br /> POTASSIUM IODIDE),8, til DF t O P <br /> X <br /> s'Nort-RCPA hazardous Waste,Lige d(Das Lan) � DF �5 g 311 <br /> 4Non-RCRA Faazardlous Waste.Solid(Urne Fillers) � 'IF P 352 <br /> 14.Special Handling Instructions and Additional Information oC=--nt: 2,% <br /> 1)070131570Z12ES -)—Xl S 3)070131570-31282 X <br /> 2)07013775x9959 PRG#171 1)(I'S' 4)070127455-1 D599 j X 3 Q <br /> 15. GENEM70R'S/OFFEROR'S CERTIF1CA110W I hereby declare that the conlents of this oonsignment are luty and acwrately described above by the proper shipping name,and are dassiSed,pad(aged. <br /> marW and tabeledrplacarded,and are in an respells in proper Condition for Transport aawding to appBphlo international and national governmental mgWations.If export shiprnent and I am tie Primary <br /> Exporter,I eertlfytlhat the contents of this consignment oonform to the terms of the attached EPA AddpM4mentof Conserd. <br /> I cerfiEy fiat the waste aftnaafian ssatameol idenVied h 40 CFR 26Y.27(a){d I am a large quantity generator}or(b)(di am a sman qpa"generator)is true, �7 f p <br /> roto aJDte PrnfledlT Name JJ Shgnahae _17 DW Yew/—1 <br /> h L� d. 77 <br /> 16.IntemaGenal Shipments <br /> F-- ❑Import to U.S. ❑Export from U.S. Port of entryfexlk <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TranhsporterAcknaMedgmemis <br /> of <br /> Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> Q0 5 <br /> T rte 2 AnWyped fiamp Z (Zigna' Morth Day Year <br /> � Ll J <br /> 7B,Dsaopancy <br /> 1 Ba Disco xy Hkaboo Space ❑0..:ity ❑Type ❑ estdue ❑Partial Reject. ❑FO Rejection <br /> Mantled Reference Number. <br /> 1Bb.Allemato Fadfly(or Unerator) U.S.EPA ID Number <br /> zi <br /> C> <br /> "6 Fadlity's Phone: <br /> LOU 1Bc.Signature of Attemate Fadrly(or Generator) Month Day Year <br /> 19,Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU c 1. 2. 3, 4. <br /> Linn <br /> 20.Designated Fadttty Owrhe for CentTicat on of pt a[ rials red by the manifest except as noted i 1 Ba <br /> PrhWdgyped Name Signature Year <br /> L71 D Q! <br /> EPA Form 8700-22(Rev.1 -17) PreMoud editions are obsolete. DESI NATER FACILITY TO EPA's PST SY T M <br />