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Please print or type. Form designed for use on elRe 12-pfh)b ) Form ' <br /> Approved.t]M8 No.205000.49 <br /> UNIFORM HAZARDOUS 1•Generator ID�o� 2.Pape 1 of 3. Phone a.Mom T np wmlxr <br /> WASTE MANIFEST CAL 000 379 517 1 (�a _3975 JJ K <br /> sEMISAN <br /> c.weaWs Wn ani Mal g <br /> alhg Agar n r�MgRT Se Fl NAS.;1693 Generamrs Sne address Pf dthrent I um mMV aft=) <br /> C3ELE8,CA OLEADA190051 LODI,CA 9 240 NUE <br /> Genaretors <br /> Ihnne: (20M 365-6713 <br /> S.Transporter 1 Name U.S.EPA ID Number <br /> EQ 1NDU8TRIAL SERVICES I NK 433 642 742 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> BED ROCK INC.DBA TSW=0 MOD 495 438 998 <br /> S.Designated Fediay Name ard Sae Addreu U.S.EPA IU Number II <br /> US ECOLOGY IDAHO,INC. <br /> 20400 LEMLEY ROAD IDD 073114 6% <br /> GRAND VIEW,ID 83624 <br /> Eadmo Phone: 274-1516 <br /> S& 9b.Us.DOT Dow"orl Ifndud+mg Prq-Shippng Name,MM20 tw.ID Number, ia.ContaMars 11 TOW 12.Udl 13 Yvaste Callas <br /> HM and Paddmp Group(d&y)) No. Typo 0=* WUVd. <br /> w X 'UNION,Mk to AW08*,2.1 (DOT SP 11298),ERG*120 001 DF 00009 P D001 D002 331 <br /> X 2UN3286, <br /> VlNste Corrosive>iW,basic,hw9oric,nos. 001 DF 00008 P D002 122 <br /> (Sodhan Hy tolde,Potasslnm Hy*wd b),84 Pall.ERG 8154 <br /> X 3UN1791,V*de Hypodllorlte sahNioitls,8,PGII,ERG 44154 001 DF 00012 P D002 122 <br /> l <br /> 4lon-RCRAHWWdW3 V"o.LigtW(Ca maw Ptsoalds) 002 DF 00087 P 331 <br /> 1 <br /> ia. rmstn,cMons Addltiond Inlnmaaon �' <br /> 1. HVIA1 I HVVDI- AEROSOLS 2.SFHW04 f SFFMM-CORROSIVE BASE LIQUIDS&SOLIDS 3.SFHVV05I SFHW05-BLEACH& <br /> BLEACI-ISPILL.ClEANIUMMORBANTS ,.SFNHWDI J SFNHVgM-NON-HAZARDOUS UCIUIDS&SOLIDS 1P:t4.19.7M5.17I <br /> 15. GENERAMWSIOFFEROR'S CERTFICATION:1 Mosby declare that Mrs oWerh of this oorelgra eci are Nny and emratdy desraned ab—by the proper al ipp4,g name.aid are deastaed,padmped, r <br /> madud and Iabdedfplaoarded.emd are In al respects in proper mndaion br transport aomr W b applicable IntemaftW and naboml owerrunoW iepuWws.$export Wpment arW I am Its Primary <br /> Etiporter,+mrtlk tlbt the eantents of ihks oonsigrenerrt mrrlomr to ere tomo of aw atnrired EPAAdmarAedgmenl a[Coruent. <br /> 1 ce*that the wm W mhdmiWM staWn d IdeHlfied n 4l1 CFR 262.27(a)(M I am a lege Wanly generator)or(b)rd'am a small"vAky penaator)b hue. <br /> I <br /> s PrLnWW Nae R of SMART&FINAL STORES LL( Money Dail yew <br /> ptol 08 1 16 119 r <br /> r i .hmemaMar>al 5hiprtximts ❑wpal to ❑Expm 6om U S. Pod of mvyk* t <br /> Transporter sdgnatum(for evores o+MY): Date bawy U.S.: <br /> 17.TranspoftAdmow4e4mwtof Roe*of MalerM ` <br /> cc T 1 Name M th Day Yber <br /> Qty s e t .S I r 08 16 19 , <br /> ra <br /> TmzpMor 2 PrirteCyped Name sgrubme Month Dey Year <br /> IY <br /> 1a.Dlsaeparrry <br /> 19a Dispepmrwy Yr9raMon <br /> Spot ❑ Y ❑TYpe ❑Rsstd!e ❑ParW R*c6mr ❑Full R*dim <br /> Mandest lietarenoe Numb <br /> 1$b.Allemale FadAty(orGanerdA US.EPA1D Number <br /> c�a I <br /> I <br /> I FuWs Phoma: <br /> lar-S nnkn of ematm FatiRy(or i y <br /> S2 19.tlaxar foes Weate Report Management Method Codes p.e,codes for hazardous waste treatment,dtspeow.and re "m►eme) <br /> 1. H141 H132 a H132 4. H132 <br /> 21i.Desipnmled Faa'61y Owner a Operator Certla®tion of receipt o(hazerdnrs materials muted by Mrs mentkst except as ndad n Item 18a <br /> PMWTyW Name <br /> Month Day Year <br /> EPAForm 8700.22(Rev 305) Previous eMMS are obsolete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) { <br /> t <br />