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<br /> Please print or type.(Form designed for use on elite(12,piich)ty awritar.) Form: proved;OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2;Pa=3Emorgenoy Response Phone 4.M lfest Traction Number
<br /> WASTE MANIFEST CA 757 20
<br /> b11M343 FL
<br /> 5.Generator's Name and Malling Address Generator's Site Address(if different than mailing address
<br /> Eiwfer Tfacy Gotrrr unity Hospital r- Tracy Community Hospital
<br /> 1421 N `rac BIS N 144907
<br /> 1'rai,.y, A� 7Cs 1 T y,
<br /> Generator's Phonal j
<br /> 6,Transporter t Company Name U.S.EPA ID Number
<br /> Heaithase Services CALOW37D179
<br /> 7.Transporter 2 C�4omnany Narita IX&F„PA 1D"Nowber
<br /> 6 Deslgluded Facility Name and Site Address VS.SPA ID Nott!(%
<br /> tIMr 11 11) s South of Beatty X11
<br /> 11tafty, tqv 4
<br /> Facility's Phone: 776-%3-2
<br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11,Total 12,Unit 13.Waste Codes
<br /> HM and Packing Group(if any)) No. Type Quantity WcNol.
<br /> 1Nori-RCRA I-1 ;ardous Waste, Liquid(Buffered Formalin) 343
<br /> ® DFS® P
<br /> 2UN3264, Waste Corrosive liquid, acinic, inorganic, n.o,s, 791 0002
<br /> (HYDROCHLORIC ACID, SULFURIC ACID), 8, If / DF P
<br /> ,3UN9014, Waste Hydrogen peroxide, aqueous solutions, 5.1 (8), : P LSF / � 141 1001 2 '
<br /> I
<br /> 'NA 2, Waste Hazardous waste, liquid, rli (CHROMIUM, 135 0007
<br /> X POTASSIUM IODIDE), 9, III I ®F 05 P
<br /> 14_$pedal Handling Instructions and Additional information Document. D2
<br /> 1)070131 57(-L"i 2 aX(5~ )70251287-0 ER 140 I X5
<br /> 2)070137708-9756 ERG#154 1 X 15 4)0701377 Eft 1711
<br /> �5
<br /> 15. GENERATORVOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper stripping name,and are classified,packaged,
<br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international 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 EPAAcknowiedgment of Consent.
<br /> I certify that the waste minimization statement identlfled in 40 CFR 262.27(a)(if I am a large quanOtygenerator)or(b)(if I am a small quantity generator)is true.
<br /> es otypedmeariaoto ronao
<br /> D rt3 I�
<br /> r 16,International Ship
<br /> ' ❑Import to U.S. ❑Export from U.S. Port of entrylexiC
<br /> Transpoilersl nature(for'es tails ant` Date laavli U.S.:
<br /> IX w 17.Transporter Acknowledgment of Receipt of Materials
<br /> Transported pnowTyped N signature on ay ear
<br /> O ` 23CL
<br /> ZTransp 2 'ntedt pad Name ay Sar
<br /> 18 Dis,emincY j
<br /> 18a.Discrapanc ndteailon Space ❑ Quantity ❑Type ❑Rgaiduo ❑Partial Rejection L_J Full Rejection
<br /> Manifest Reference Number,
<br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number
<br /> .r
<br /> U
<br /> Q
<br /> r' FadGt's Phone:
<br /> W 18c:Signature of Alternate Factiiiy(or Generate Month Day 1a{ry:'
<br /> Q
<br /> Z
<br /> 19.Hazardous Waste Report Management Method Codes(t6.,codes for hazardous waste treatment,disposal,and recycling soerns),
<br /> o 1lug 12, 3. t 4.
<br /> t1: 1 a I:�l —
<br /> 20,Dosigtiatad Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as to Item 18a
<br /> PkiulotllTyftadName &Ignatluts on Day; Year
<br /> EPA Form 8700-22(Rev. Previous editions art
<br /> f bsolate. ----"�—IFSIGNAIMTZIITY TO DESTINATION STATE(IF REQUIRED)
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