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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST . CAR000220046 1 909-984-9984 016408886 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) CALIFORNIA HEALTH CARE FACILITY (07557) 7707 SOUTH AUSTIN ROAD 7707 SOUTH AUSTIN ROAD (attn: Anthony V) STOCKTON, CA 95215 (attn:Anthony Vanni) STOCKTOX, CA 95215 Generator's Phone: 209 467-7904 6.Transporter 1 Company Name - U.S.EPA ID Number INDUSTRIAL WASTE UTILIZATION, INC. CAD980585293 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number US ECOLOGY HWY 95, 11 MILES SOUTH OF BEATTY BEATTY, NV 89003 Facility's Phone: 800-239-3943 NVT330010000 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1• UN2924, Waste Flammable liquids, corrosive, D001 D002 331 pX n.o.s. (ammonia/ethyl alcohol) , 3, (3) , PGII Z 2. W 3. I r 4. 14.Special Handling Instructions and Additional Information 1) ammonia inhalants-070314662-0; ERG #: 132 0 J X&B at 15. GENERAT 'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am ffmall quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year 16.International Shipments I- []'import to U.S. ❑Export from U.S. f e t /exit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Si t e Month Day Year z Transporter 2 Printedrryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ ❑Full Rejection ❑ Quantity El Type Residue Partial Rejection j Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U ra+- Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pri /Typed NameSig ture Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM I