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Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1enpralgGlD dymgpf O ,' 4 O 0 3 2 Page 1 of 3.Emergency Response Phone .Manifest Tracking Number WASTE MANIFEST AA LL �j �J 1 (209) 983-9199 012772979 FLE 1 p 8 r 1 t la"Iminailddross W ralac's SlteA�ross(If dllfaronl than mailing address) 85 E LOUISE AVENUE 85 E LOUISE AVENUE LATHROP, CA 95330 LATHROP, CA 95330 Generalor'sPhone: (209) 983-9199 6.Transporter 1 Company Name Us.EPA ID Number BELSHIRE CARO 0 0 1 8 3 9 13 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number U,S_ Eco gy Nevada Operations 9 V T 3 3 0 0 10 0 0 0 Beatty, g�oWes S. of Beatty Y, Facili 's Phone: (775) 553-2203 ga 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 WI.Nol. t Non-RCRA Hazardous Waite, Solid (ERG #171) P 352 *DO18 O (Rags, absorbent, & debris impacted with Q petroleum hydrocarbons) 4alj z 2 w 0 4 FOLD1d.Speclal Handllrrg Instructions and Additional Information ante 3.5 exunpt: r om B Ei S I • f Q 9 l9 9 B 11K.IABD ' Generator is a RC". V9QG as defined in State and Federal. Land L10E AFFIBA 90 CFR 260.10. D016 code re resents 910E OF IIA p Disposal Restrictions MATTi{IALBIU waste that is RCRA identified but not PROFILE # 070219257-0 2.�C�cS TABSTIC1fSAl RCRA regulated. 1111014 15. GENERATOR'SIOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,end are classified,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable Intemationaland 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 EPAAcknoMedgmenl 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)(ill am a small quantity generalor)is true. GoreratcesfOfleror's Printe�lTypod Name Signaluhr Month Day Year r ; � J 16.Inlemational Shipments ❑Import to U.S. ❑Export from U.S. Pcrtof entryfex h -- - Z Transporter signature(far exports only): Date leaving U.S.: W 17.TranspoderAcknowtedgmentof Receipt of Materials w Month Day Year F- Transporter 1 PrintWylred f Signature 1. �p�\ An joci I le Z Trmsfrorler 2 PdntedfTyped Name Signature Month Day Year 18.Discrepancy tea.Discrepancy Indication Space ❑ puanfily ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection hfanllasl Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number J U U- FncildysPhone: LO 18c.Signature of Allomale Facility(or Generator) h",onth Day Year Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 ?_22 3. 4 20.Designated Facility Owner or Operator:Cedificadon of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printu'<l lame Signa to Mon r ton Ale EPA For 700-22(Rev,12.17)Previous editions are obsolete. DESIGNATED FACILITY TO EPA's a MANIFEST SYSTEM �S,E Lcu 6S IC1 13909