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022804094JJ K <br /> Please print or type. Form Approved.OMB No.2050 WN <br /> UNIFORM HAZARDOUS t_Generator iD Nunsber 2.Page 1 of 3.Emergency Response Phone 4 iianlfest Tracking Number <br /> WASTE MANIFEST CAL00046=5 i [q 7e5-713a 0228 0 4094 J J K <br /> 5,Generator's Name and Mailing Address Generators Site Address(idifferent 4m marling address) <br /> ATTR MICHAEL MILLS USF C14EFSTORE 7S17 STOCKTON 8502 PACIFIC A IE <br /> 1600 BLANKENSHIP RD SUITE 250 STOCKTON, CA 95207 USA <br /> )MIST LINN.OR 97069 LISA (709)477-0596 <br /> Generator's Phone: <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> US Ecology Transportation Solutions, Inc (734.)521-SWO MIK5937431M <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> BED ROCK INC. DBA TSMTCO (417)824-3131 MOD095038998 <br /> a Designated FadGty Name and Site Address U.S.EPAM Number <br /> HIGHWAY 95, 11 MILES SOUTH OF BEATNTOY NVT3=10000 <br /> BEATTY. Hilt agWS USA <br /> Faa1AlrsPhom: (T75)553-2203 <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 PacklN Group Cf any')) No. Type Quantity WtNol. <br /> 1 Non-RCRA Hazardous Waste, Liquid (Consumer 331 <br /> pruducts) 1 DF 15 P <br /> a 2. <br /> LU <br /> (7 <br /> 3. <br /> 4. <br /> .S <br /> 14.Special Handling Instructions and Additional Information <br /> i.i.SPiili"fti i FICIN-Fieu LIO iOS&SOUDS(s A E REG) [T.14'.�tfi910M08.281 <br /> 5 i Y. <br /> ROY U <br /> 15. GENEMATOWSIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of Cris consignment arefuly and accurately described above by the prWshl�ppipingq name,and are classified,packaged, <br /> marked and labefedlplacarded,and are in all respects in proper condition for transport araortlbtg to apomble International and rational gavarm emal regulafiomi.tl export shfpment and I am dw Primary <br /> Exporter.I certify that the contents of MIs rmsornent confamn to the terms of the aUached EPA Acknoxtedgment of Consent <br /> cwtfy that the waste min mixation staternent idenlified In 40 CFR 26227(a)(41 am a large quantity geeerabr)or(b)(dl am a small qumW ge ralor)is We. <br /> Generalersi0flerorsyped Naxr�e Signature MMM Day Year <br /> T"' .ri 1 k it, tie 1 23 22 <br /> 1 <br /> 16.1 nternational Shipments <br /> ❑Impel to U.S. ❑Effort from U.S. Part of errbylexiC <br /> Transporter signature(for exports only): Data leaving U.S- <br /> 0! <br /> .S. <br /> � 17.TransporterAcknovAedgment ofRecelpt of Materials <br /> a T ler�1 Printedliyped Name Signatu Month flay Year <br /> C 7r4 YnPYL !_ 06 1 23 1 22 <br /> 9 <br /> M <br /> P'nf igna Mmih t0ay'�ear <br /> dam, 6 I! <br /> tB. istroyanoy <br /> 18a_Discrepancy Indrabon Spam ❑ ry [—]Type ❑Residue ❑Partial Rejection ❑Fug Rejection <br /> r <br /> Manifest Reference Num W.. <br /> I5b.ALrnate Facility(or Generator) - U.S.EPAiD Number <br /> J_ <br /> LJ <br /> Y Facility's Phone, <br /> W 1 Be.Signature of Alternate Faality(or Generator) Month Day 'Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyrllrg systems) <br /> 4 1. 2 j 3. 4. <br /> H= <br /> 2f1.Designated Facility tor:Ceitfiradn Okegqpt of hazardous materials covered by the manifest except as rrcled In Bern 18a <br /> Print W Name ahue y <br /> '+'y' <br /> EPA Form 87110.22(Rev.12- 7) P etiousedG ns&a obWeta. -MANIFESTS M <br />