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Please print or type. Form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTEMANIFEST CAL92004003 I 1-336Z4742357 013525598 FLE 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Doctors Has0allilarlwsa DoclorQ ia�pitali,iani�ca !105 E Noirth St 1205 E Naith SI !Jahteca, CA 95335 Ivlatitec i, CA 95336 Generator's Phone: 559-3t74-4963 6.Transporter 1 Company Name U.S.EPA ID Number �::tra �ilYffJillilia�tdi Jrsk11IJI1S ;rAR9JJ�9522G 7.Transporter 2 Company Name U.S.EPA ID Number i 8.Designated Facility Name and Site Address U.S.EPA ID Number US ECOLOGY NEVADA ��tfr�aoalo of 95 :' N;JCs SGulh af6ratty Facility`s Phare: 775-553-2iX; 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 PacAnng Group(ifany)) No. Type Quantity Wt.Nol. 3 0 �'Y.Siz, uatr`i� 1Gi1i I Cir- I Lu Lu 2. w 3- 4.. 14_Special Handling Instructions and Additional Information Dof,•(jment: .�Ji C:J.�.1J134''•7 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by he proper shipping name,and are classified,packaged, marked and labeleWplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulat ons.If expo shipment and am the Primary Exporper,I cert fy 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 a small quantity generator)is true.GT- Month Day Year Signature 14n J +on j I� Offerors Pdnted/Typed N e 1 __j 16.lntemabonal Snrornents ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Z TranspoWs4r naWre(forexporisonly): Date leaving U.S.: IY 17.TranspaterAakrvwl*ffient of ReOe pt of Materials aggDpp 1 Month Day Year LJJVpoW 1 Pmted7yped Name S 7/ /e �0 (S x'e ��A�/`I SignUafur Month Day Year Z Transporter 2 Printefflyped N t-- 16.Discrepancy 18a.Discrepancy Indication Space El quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: U.S.EPA ID Number � 18b.Alternate Facility(a Generator) Facility's Phone: Month Day Year j 18c.Signature ofAltemate Facility(or Generator) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba 'rintedlfyped Name Signature Month Day Ye )rm 8700-22(Rev.12-17) Previous editions are obsolete, DESIGNATED FACILITY TO EPA's e-MANIFEST SYS