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T <br /> Please print or type. Fcrm Approved,OMB Na.205010039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Fume 4,Mandest Tracking Number <br /> WASTE MANIFEST CADD7$79092g 2 1 g6547.2$7 012218673 F L E <br /> 5.GerrcraloftAName and MaifugAddne`;s Generators Sim Address(if dilferant Uran mailirg address] <br /> Sutter Trary Corffml:tiny Hospital Sutter Tracy Commututy Hospital <br /> 1420 N Tracy Blvd 1 420 N Tracy Blvd <br /> Tracy, CA 95376 Tracy, CA E5376 <br /> Generators Phone: SS94W-M <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Atlas EW%inmerdal SDIi iofls CALM0435%4 <br /> 7.Tan r2 Company Name U. EPA ID Number i <br /> e Phi l4 8 MY <br /> 3'l OK6 U.S,EPA ID Number <br /> M'y 95, 11 Miles.South of Beatty 1W r=10w0 <br /> Buitty, NV 62003 <br /> Fadfi 's Phone; 775-553'2203 <br /> ga, ft U.S.DOT Description(L,audng Proper Shipping Name,Hazard Class,ID Number, 10,containers 11,Total 12.Unit S3.Waste Codes <br /> NM and Paddrg Group(dM)) No. Type Quantity wtrvo. I <br /> cc 1.U=164,Waste Carresi a Iigt4d,acidic, inorganic,n.o.s. 791 0102 <br /> X (HYDROCHLORIC ACID, SULFURIC ACID), 8, II j DF A I <br /> z.No;�RCI3A Hazardous Waste, l igrd(ail) P 221 ' <br /> 1 � � <br /> 3•Non-RCRA Hazardous Waste, Liquid(Des1i } 3g1 <br /> ! 3$ p <br /> 4.horti Hazardous Waste, Solid (Lime Filters) 352 <br /> OF f 'S" P <br /> 14.Special i instructions and Additional Information ef11: V r <br /> 1)07013770&WSSa ERG4154 rxi!9'-" 3)070131SM31282 he l:�— <br /> 2)M131510.31945 I V A 4)0701 27495-1 05s 1 X)s <br /> 15. GEN ERATOR'S10711 OR'S CERTIFICATION:I hereby dociare Shat the content,of M consgnmentara fury and accurateiy described abmra by the propershipping name,and are dassfed,packaged, <br /> rnarked and Iabeledipiacarded,and are kr all respects in proper condition for transport according to appficaWe Intem flonaland national gevemmental regulations.Hex rt shipment and I an the Primary <br /> Exporter,I codify that Uro contents of this conslgnmerd conform to ft terms of the attached EPAAcknadledgment of Consent. <br /> I certify that Uro waste minimira0iorr statement Identified in 40 CFR 26227(a)(d I am a targe quantity gonerater)or(b)(if l am a smatl quantity generatlor is true <br /> ratorslOHerors P Name Sig _ Month Day Year <br /> l zz <br /> ,r>Infema srUprnerds <br /> P- ❑Import to U.S. Eli from U.S. Fort of entrylexit I <br /> 4 Transporter signature(for exports onfp): Dale leaving i <br /> cc 17.TramporterAdmovAedgmentofReoeiptofMatedals <br /> IJU <br /> a Tran porter 1 Pfinta&Tged Name Signature Month Day Year <br /> A atri�r� TO 1I Z. 1 <br /> Nrtanspwter 2 edlryped Name <br /> Signatu Month Day Year <br /> 18.Diwrepangr <br /> 188.Discrepancy Ind icafion Space ❑ Roantity ❑Type ❑Residue Parw Rejection ❑Full Rejection <br /> pr,VMA �0vi +vii r�e.r-.03 4A_ R-. VIE 0 11 VVIi 1f(r - a 7S�F �► <br /> Manifest Reference Number. v� ! <br /> 18b.Altamate Fadi(or Generator) US.EPA ID Number 1 <br /> U <br /> Far10:i Phone; , <br /> LOU t&Slgnatura 01 Almmate Facility(or Generator) Month Day Year <br /> ytg.H=rdcKz V Ste Report Management liMi codes Co..codes for hazardous waste trearmerrt,c ispasal,and rung systems) <br /> LU 1, 11, JAM 1 3, 1 14, <br /> 20.Designated Facility Ramer ar Operator.Certification cf realpt of haz;3rdous mater Is covered by this manifest e4ept n in item f Ba <br /> PrinteVyped Name e e Sgnature Month D Year <br /> f <br /> EPA Form 8100.22(Rev. 2-17) Previous editions a o oiete. ESIG D FACILITY V 41FEST SYST <br />