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r <br /> Please print or type. FormAppmved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page l of 3.WR WMATkfanifestTracking Number <br /> WASTE MANIFEST CAL 000 379 505 1 T020590260 <br /> JJ K <br /> 5_Generatces Name and Mallin Address Generator's Site Address Id different than malting address) <br /> ATTN:NICOLE9ADAM 147 N.WILSON WAY <br /> P.O.BOX 512377 <br /> LOS ANGELES,CA 90051 STOCKTON, CA 95205 <br /> Generator's phone:' 209 464-3829 <br /> 6.Transporter 1 Company Name U.S.EPA l D Number <br /> EQ INDUSTRIAL SERVICES MIK435 642 742 <br /> 7.Transporter 2 Company Name U.S.EPA Il]Number <br /> DED DOCK INC,DBA TSMTCO MOD 095 038 998 <br /> 8.Designated Facttity Name and Site Address US ECOLOGY IDAHO INC. U.S.EPA ID Number <br /> 20400 LEMLEY ROAD IDD 073 114 654 <br /> GRAND VIEW,ID 83624 <br /> FadliVs Phona: (800) 274-1516 <br /> 9a. 9b.U.S.DOT Description[ndudeg Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Und <br /> 13.Waste Codes <br /> HM and Paddog G-p(deny)) Na. Type Quantity WtNd <br /> X 1. RQ,UN1993,Waste Flammable liquids,n.o.s.(Acetone, 401 DF 04033 P D001 U002 D81 <br /> o Benzene),3,PG11,(RQ:D018),ERG#128 <br /> 331 <br /> W X 2. RQ,11N3268,Mste Corrosive liquid,basic, inorganic, n.o.s. 044 DF 00146 P D002 12 <br /> (Sodium Hydroxide,Potassium Hydroxide),S,PDII, (RQ: <br /> D002),ERCP#154 <br /> X 3. UN1791,Waste Hypochlorite Solutions,8,PGII,ERG#154 001 DF 00019 P 0002 122 <br /> 4. <br /> 145.gcl ao rnglnstructlonsandAdditimallnformatcn <br /> 1. I LI SFHM2L-FLAMMABLE LIQUIDS 2.SFHM I SFHM-CORROSIVE BASE LIQUIDS&SOLIDS 3.SFHW M I SFHVYM <br /> B4.EACH&BLEACH SPILL CLEANLIPIABSORBAMTS IT:14.19.71546.111 <br /> (ob S�CoCv <br /> 15. GENERATOR'SIOFFEROR'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, <br /> marked and labeledfplacarded,and are In all respects in proper condition for transport according to applicable intematienaland national governmental regulations_If export shipment and I am rhe Primary <br /> Exporter,I certify that the contents of this oonslgnmenl conform to the temrs of the attached EPA AdvroMedgmentof Consent <br /> cer*that the wasta mirdm¢a5m statement identified in 40 CFR 26227(a)(d I am a targe quantity generator)or(b)(11 am a smog quantity generator)Is true. <br /> Generato rots Printedayped Name On Behalf!MT&FI PIAL STOR ES UA Month Day Year <br /> ' W">_0 1 091 251 19 <br /> 16.latema onalSJhipments <br /> ❑lmpat to U.S. ❑Fxporf from U.S. of entrylexir <br /> TrdnspWr signature(for exports cnly): Date"U.S-, <br /> W 17.Transporter Adm Wedgment of Recelptof Materials <br /> �i er 1 Pdntedlfyped Name Stgnat Month Day Year <br /> LL )m ,. AnIA 11 1 091 251 19 <br /> y Transporter 2 Pdntedffyped Name Skyhe4_ Month Day Year <br /> F_L.v IN , 1101071/7 <br /> 18.Discrepancy <br /> 1t3a DistreparxyfrdtatiortSpam ❑ (tuanny ❑Type ❑Residue ❑PartialRej.6. ❑FufiRejection <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 'I Be.Signature of Ntemate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> y %l-mwdous Waste Report Management Method Codes[a.,codes for haxardaus vraste treatment.disposal,and recycling systems) <br /> O 1. 2_ 3. 4. <br /> H141 I H132 H132 <br /> 20.Designated Fadity 0wneror Operator:Certification of neoelptof hazardous materials covered by the manifest except as noted in Item 15 I <br /> P' yp2d Name are ��tthqear <br /> h JDay Y <br /> U 1 <br /> EPA Form 8700.22(R v.12.17) Previous editions are obsolete, ESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />