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r•• <br /> .Please print or type. - Farm Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS I•Generator IA Number 2.Page 1 of 3.Ergmo lte ngg.EhoAe 4.Manifest Tracking Number- <br /> WASTE MANIFEST CAL 000-280 768 1 1-aUU 4D 1-i3.34i1 020'592391 J J K <br /> 5.Generators Name and Mab Address Generators Site Address d different Van mating address) <br /> A4TTN:FUEL STATIOIN MANAGER fi425 NORTH PACIFIC AVE. <br /> STOCKTON,CA 95207 :, STOCKTON,CA 95207 <br /> Generalor's Phone: 209 472.8600 <br /> 5.Transporter 1 Company Name U.S,EPA ID Number <br /> EO INDUSTRIAL SERVICES MIK-435 642 742 <br /> 7•Tramporter 2 C*mMy Nam - US.EPA ID Number <br /> BED ROCK INC. DBA TSMTCO MOD 095 038 998 <br /> 8.Designated Facility Name and Site Address US ECOLOGY IDAHO, <br /> INC. U.S.EPA ID Number <br /> 28400 LEMLEY ROAD IDD,073114 654 <br /> GRAND VIEW,ID 83624 <br /> Facpility'sPhone: (800) 2741516 <br /> ga. 9b.U.S.DOT Description(Inckd g PmperSKppmg Name,Hazard C4ass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Paddng Group(d any)) No. Type Quantity WLNol. <br /> 1ROY UN1943,Mste Flammable Liquids n.o.s.(Gasoline, 001 DM 00149 P D001 D018 36 <br /> Diesel),3,15011,(RQ:D018), ERG 0128 <br /> X 2. UN3175,Solids containing flammable liquid,nos.(Gasoline, 001 DM 00078 P 352 RECG <br /> Diesel)„4.1,PG 11,ERG#133 <br /> 14.Special Handling Instructions and Additional Information <br /> 1.AB8BWFSI IASSHWFSI-HAl LIQUIDISOLID FUEL STATION WASTE 2.ABSNHWFS2 IABSNHWFS2-DRAINED FUEL FILTERS I t <br /> Excluddeed Recrclabia Material(Dralmd Fuel Fitters)IT:14.19.73436.21 <br /> 15. GENERATOR'SIOFFEROA'S CERTIFICATION,I hereby declare that the contents of this consignment are fuily and accurately described above by the proper shipping name,and are dassitied,packaged, <br /> marked and labeledlplacarded,and are In ad respects in proper co dilion for transportacoording to applicable international and national gmrnmental regulations,t export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAckknowtedgment of Consent <br /> I certify that the waste mlNmlzation statement Identified in 40 CFR 262227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. <br /> Generators Mrars Printed(Typed Nami�/iqoc <br /> - gn Month Day Year <br /> avir 11 12 021 19 <br /> 18,tMemational5hipments <br /> ❑Impart m U.S. ❑Fort From U.S. Part of entrylexdt: <br /> Transportersignature(fpr exports only): Date loaving U.S.: <br /> W 17.TransporterAckrzyAedgment of Receipt of Materials <br /> a E(%Printed(Typed Namena ur q Month Day Year <br /> sI�0 NN NA-A 121 021 19 <br /> Tratporter 2 Pnimed/T�yped Name S%alure Month [3ay Year <br /> r 5 <br /> 18.Discrepancy <br /> Iea.Discrepancy Indlcalion Space ❑ Quantity ❑Type El j j <br /> + <br /> ❑Portia!Re ection ❑Futi Re ecliorm <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> E5 <br /> w Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> x <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal+and recycling systems) <br /> 0 1. 2. 3. 4. <br /> H141 H141 <br /> 20.Designate adlity Owner or Operator,Certification of receipt of hazardous materials covered by the manifest excep rhded In Item 18a <br /> Pri p N Sig �� �� <br /> EPA Farm oa {Rev,12. 7 Previous editions are obsolete. []ESI MATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> • 1 <br /> r + <br />