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-. . i € <br /> PCe "rfrtt:Sr,t Pe=(I mdesigrt�d_�Orusetutt�ita(IL= ' i).'Cypec�fifer:I. :..... IAF/rrlpm��'A' rbo,�t3-6ivil .18> 050603 <br /> (A RA7A� OUg 1 Generator ID Number 2.Pegs 1 of 3.EmergBncy Respot�e Phone 4 k4a Ttgc E V <br /> 4it1'iM(�AfOiFFFtST A:tM, .S!'.9 6+- zf . <br /> 5,Oweratoes Name and Mailing Address, GengratWs Siba Address(if different than mail Ing address) <br /> St fasews Medical C-e <br /> 1800 N Calffluffla.fieSAME <br /> S'MckbSft,CA 95204 <br /> deneraWsPhone:f 91491-6ATTTi:Rwt?seandSaims <br /> 6. ransporter 1 Company Naft U.S.EPA ID Number <br /> Clean Harbort Ew&onmentalSertices IncMAP039322250 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Faality Name and Site Address U.S.EPA ID Number <br /> Clean Harbors AMonite L1. <br /> 1 .600 Rofths Mr,Road t T �� � � #� <br /> Grantsville.UT 0-29 <br /> Facili a Phone: (4351 SI-E1 <br /> ya, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Totaf 12.Unit 13.Waste Codes <br /> HM and Packing Group('d any)) No. Type Quantity W1.1vol. <br /> "UWU79.WASTE FLAMMABLE SOLID.INORGANIC- .t3_ _ 559 <br /> o r { 11 t1 00i Iia 00004 P <br /> Uj <br /> CD 00i E 000Q3 P <br /> 3.UN3289.TOXIC SOLID,1NORGANIC.N.03.,(2,. <br /> 3101ANNORENVINNE NYD $�II.ORIDE.PY I 001 D� :�€�0� 0 � <br /> 00i 00005 55i <br /> 14.Special Handling Instructions ardAdddional Infommtion <br /> I.LCCRU EERG41 1..a 2 1X5 <br /> v_FJC<F:7 is I Mx 5 <br /> RC- 1.53 2X5 <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: i hereby declare that the contents of this consignment are fully and accurately combed above by the proper shipping name,and are classitfed,packaged, <br /> marked and fabeed/plaearded,and are kr ail respects in proper cond€don far transport ecco�ng to applicable intemationaf and 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 of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement idenfffied in 40 CFR 262.27(a)(9 t am a large quantity generator)or (if I am a srnali quanfi nerator)is true. <br /> ergs Pry.WT Narrm signature/1 Mon y ear <br /> —t 16.International Shipments <br /> ❑import to U.S. ❑Export from U.S. Port of enfry(exit <br /> Tinansporter,sIgnature for exports oro : Date leavi U.S.: <br /> a 17.Transporter AckwM tof Receipt of Materials <br /> Trans 1 PrbrtedJTyped Signature Month Day 76—ar <br /> mac, �N I f2-1 Is I <br /> QTraftspOrtar 2 PdntedlTyped Name Signature month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Q.dty ❑Type <br /> ❑Reciduo El Partial Rejection El Full Rryeaion <br /> _.__ _.... ..... Manitest Reference Number. <br /> 18b.Alternate Facility,(or Generator) U.S.EPA ID Number <br /> CJ . <br /> W Fact€ s•Phone: <br /> 186.Signature ofAltamate Facility(dr Generator) Month Day Year <br /> .Uj <br /> 19:Hazardous Wastedteport Management Method Codas(i.e.,codes for Hazardous waste treatment,disposal,and recycling systems) <br /> 1. 1� 0 <br /> EP104:0 3 ��#� 1..� 040 . <br /> 20,Designated Fatality Owner or Operator:Certification of apt of hazartaus materials covered by fite margest except as noted in Item 18a <br /> Printed)Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev 3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean 14aftirs hasft a prftprtfate 0Astmits fsr and wilraef ept the Waste the'q..'Fer?erater is shi gin" <br />