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Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator Id Number 2.Page 1 of 1 Emergency Response Phone 4.Isanlfest Tme"Number <br /> WASTE MANIFEST CAD078790820 1 1-886-647-2857 1 013 5 2 5 4 5 0 FLE <br /> S.Genaretofs Name and Mailing Address Generators Sita Address(if different than mailing address) <br /> Sutter Tracy Comment Y Hospital SutterTracy Community Hospital <br /> 1410 N Traey SM 1470 N Til EM <br /> Ti CA 85376 Tracy, CA 05376 <br /> 2enerator'SPhorre:5594 7� <br /> 6.Transporter 1 Company Hama U,S.EPA ID Number <br /> AtWs Emrronn:f ntal Solutions W000295220 <br /> I.Transporter Company Name U.S.EPAILI Number <br /> tf %ec lac I CRiA zSOD sq <br /> 6.Desi naffed Facility Name and Site Address U.S.EPA IO Number <br /> US ECOLOGY NEVADA <br /> H.jt 85 1.1 Mlles South of Beatty NVT330010000 <br /> Beatty, 89003 <br /> Fadlity's Plane: 555-553-2203 <br /> ga. gb.U-S_DDT Description(Including Proper Shipping Name,He¢mti pass,ID Nwr4be, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> )jM and Pads Gw(deny)] No. Type Quandly wt Nal. <br /> 'Non-RCRA Haz.rda'as Waste, liquid (Buffered Fairii �11Fa 343 <br /> W g yf'R <br /> �$2,1r`,�3St Hazardatls t`Ii351i;,sigtlid,tt.o.5. (CiiR1�l1�{Lim, 435 0307 <br /> " x POTASSR.Orrf IODIDE),a , 10 a DF315 P <br /> 3%n-RCRAHazardous Waste, liquid(Des Cum) r qP311 <br /> 5 <br /> Nan-RCM Hazardous Waste. Sofid (rime Rlers) .� 1 DF P 313 <br /> 11 <br /> 14.Special Handling Instructions and Additional Information vowITIefa. ulaMuz- <br /> 1)01013157OZ126S hQj 3)0M /x U <br /> 2)07013775M9S9 ERG9171 a��rf 4)97012749510539 heLF <br /> 15. GEN ERATOR'SiCFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by tho proper shipping pane,and are classified,packaged,. <br /> marked and tabeledlplacarded,and are fn all respects in propermndition far transport a000rding to applicable Intemationaland national governmental regulations.If export shipment and I am the Prim* <br /> Exporter,I cerdf that Ora contents of this consignment conform to the terms of the attached EPAA&rro figment er Consent. <br /> I certify that tae waste ffkh ¢atiora statement ideriffed in 40 CFR 26=(a)lid I am a targe quantity generabi or(b)fill am a small quantity genera*is true.. <br /> c�npr�tprslfltferer�s PdritedlTyped Na rT a Signature _ Month Day Year <br /> 1M <br /> _j 15,lntemationat Stopments ❑ <br /> tmpod to U.S. ❑Export tram U_5_ Part of erahylexit <br /> ? Tmnspoi signature{for moods orti Date leaning U.S- <br /> W 17.Transporter AclaxwodgmentofReceipt ofMaterEats <br /> Tran der 1 Panledffyped Name Signature MeJ Year <br /> O ' 3; <br /> a <br /> Tra orter yped Naw Signa - Month Day Year <br /> w <br /> 15.Discrepancy L►sr <br /> 18a.Disoreparrry 44callm Spahr ❑omN ❑Type ❑Residua ❑Partial Rejection ❑Fult Re noncan <br /> Manifest Reference Number. <br /> 16b.AllematD Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fac hits Phone: <br /> W 18e.Signature ofAftemaleFacility(or Generator) Month Day Year <br /> a <br /> a <br /> N19.Hazardov,waste Report Management Method codes(1s,.Cedes for rhaEmlous waste matnont.disposal,and recy&M systems) l <br /> 0 1. 2.. 3. 4, <br /> 20.Designated Fap7oty Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as r64W 18a <br /> Pnwaanyped N Sgull re Mont, Day __Year <br /> EPA Form 8700-22(R .12-17) Previous edit i1swe obsolete. WGNATEDMACILITYTOEPXse•MA FEST SYSTEM <br />