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aj <br /> I <br /> `` ( Please print or type.(Form designed for use on eliteitch <br /> 12 <br /> ( p )typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Numbar <br /> WASTE MANIFEST cf4Do7s7D 2 , 0110 8 3 4 4 FLE <br /> 5.Generators Name and Mailing Address Generator s Site Address(if different then mailing address) <br /> j Sutter Tracy Ccxrltnttt ty Hospital Sutter Tracy Community Hospital <br /> 142E}N Tracy Bled 1420 N Trac_y�B�led <br /> i Tracy, CA 95376 <br /> Tracy;CA€t5376 <br /> Generators Phorie: . <br /> 6.Transporter 1 ompany Name U.S.EPA ID Number <br /> HealthMse Services <br /> 7.Transporter 2 Company Name , CALM=0179 <br /> .,.-- U.S.EPA ID Number <br /> 711� to � <br /> 8. e4 gnated Fadi Name and Sile Address U.S.EPA ID Number <br /> Yalta ES 'er Ecai Solutions LLC <br /> ZU Set, CA.011_)0'1 <br /> G�1000$3D�r03 <br /> i Facility's Phone: ;rm (V"X I . -A3�+. <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total. 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantal Wt./Vol.Unit 13.Waste Codes <br /> 1.UNi8S1, Waste Medcine,iicwt toxic, kdis.` UD1D U035 Ut)66 <br /> j o x (CHLORAMBUCIL; ME.LPw4LAN), J; N 3 of a Q p <br /> UD69 U150 U216 <br /> Z 12.UNia5l.Waste AAtec6c)nfa,tfc�uid;toile;n o.s. (BARIUM <br /> 551 Mffi <br /> SULFATE},S,i', it DF 30 P <br /> 3'nN2811,Waste Toxic solids;orprvc, nx s. S L), 6.1 <br /> X P iii DDIDi i DG?d <br /> 6 d5 <br /> 4'UN3107,Waste OCAartio per(Wide <br /> type E,liflUld.S,2'. 11 13.5. DODi D002 <br /> X (CONTAINS 38.,F'EROXYfiGE'Tf�.�ACI®) _ '/ D� j p.. <br /> 14.Special Handling Instructions and Additional Information DOCUITIert D24M <br /> 1)8774.35 ERC 115i,. 311 xS 3)877436 ERMS4: X& <br /> 2)877434 ERC#151PERM 45. <br /> i 15. GENERATOR'SIOFFEROR'S CERIIFICATION: I hereby declare that the contents of this consignment are fully and aocurataty dascribed above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> neratoes Offerors Printed[Typed Name Signature Month __I3ay__Y55­r <br /> —# 16.International Stffipmenff <br /> i Z ❑Import to U'S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature for exports only): Date leavN U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials. <br /> Transporter 1 Printedrryped Na Signature on ay Year <br /> O <br /> a Z gC <br /> � J <br /> n er rin ype a ignaMonthay ea <br /> t! <br /> 18. rscmepancy <br /> 18a.Discrepa indication Space ❑ Ouenti <br /> ty ElType Residue. ❑Partiai Rejection ❑Full Rejection <br /> I Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> j <br /> Facilitys Phone: i <br /> i LOU 18c.Signature ofAitemate Facility(or Generator) Month Day Year <br /> Q <br /> i z <br /> I 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and repycling systems) <br /> 4. <br /> I 20.Desi nated Facility gwrer or Operator:Certificatbn of receip of hazardous materPals covered by the 2fesr&ept as noted in gem I Be <br /> I Pri t P WA <br /> t r 11 <br /> EPA form 87b0_22(Rev.3-05) revio s editi ns are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> I <br />