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Please print or type. Form Approved.OMB No.20M4039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.11guyl n 4.Manifest Tracking Number v <br /> WASTE MANIFEST CAL 000 2$0 76$ 1 rim 1020590873 J J K <br /> 5 tan r tgs rte r l,ili�q�[�Is{CAV Wk t,9 Generator'sZrJ N��I flePACIFIC AVing E. <br /> ATTN: TFUEL, INSFTHATION MANAGER i <br /> STOCKTON,CA 95207 STOCKTON,CA 95207 <br /> Generator's Phone: (M)472—SM <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> EO INDMAL SSMtCM WK 435 64:2 742 <br /> 7.Transporter 2 Company Name ,�y. U.S.EPA ID Number <br /> M�1w,' TSMTCrO .r��r'�1�' C` MODwe 08 <br /> B.Designated Facility Name and Site Address US ECOLOGY IDAHO,INC. U.S.EPAID Number ` <br /> LE+f.� �IlEiif VT�y1 ■!1 AD IDD 073 114 <br /> 654 <br /> GRAW V 10 4 <br /> Faclily's Phone: 274-1516 <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 Wtivol. <br /> D$on%3,PGI1,(RQ-.DOI$),,ERG 9128 <br /> 2 �{ 2,;[t 3#7 , a!>a ftiarniabIde BqL*d,mo s_jGawfte, 001 DM OMI P 352 MCG <br /> Dk-seI•j,.4.t,PGI1,ERG#133 <br /> 3.. <br /> 4. <br /> 14.5. a andlER <br /> ' Instru 'ns a a Int at' <br /> Ea>rkl6ad R,%jfcL$t!a V;&ewl pvabM Fw Fix)11:1419.71AW.] <br /> (00q$0 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this oonsignment are fully and accurately described above by the proper shipping name,and are classi5ed,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition fortransport according to applicable intematie 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 ofWunt.1 <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b dl am a mag quant genemtar)is true. <br /> Genera&sJ0ffq&s Printedrtyped Name Signature Month Day Year <br /> 0 17 19 <br /> 16.International Shiplients <br /> F ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> s Transporter signature(for exports only): Date leaving U.S <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> LU <br /> � Transported Printedffyped Name Signature rte" Month Da Year <br /> FTra �2 PriinteCUTT Year <br /> u <br /> Month Day <br /> 18.Discrepancy <br /> 183.D screpancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re]eclion ❑Full Rejection <br /> Manifest Reference Number, <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> a <br /> U <br /> t¢i. Facility's Phone: <br /> C3 18c.Signature of Allemate.Facility(or Generator} Month Day Year <br /> 1 <br /> V519.Ha dws Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1,. H I41 2• "149 3. 4. <br /> 20.Oes[grl#d Facility Owner or Operator:Cerifica' f receipt of rdous materials oovered by the manifest exce nded in Item 18a <br /> EPA P44412'11-X-17) <br /> d Name � Si !Nayf far <br /> Previous edi0onsare obsolete. DESIGNATED FACILITY-TO EPA's e-MPAIFEST SYSTEM <br />