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b � <br /> Ple. .print or type.(Form deslgned for use on elite(12- 10)f rlter,) � /J Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS, 1,.Generator tuNumber -TdH �q. . 0171".ng Numbo <br /> 14.Manifest TrarkirWASTE MANIFEST 000 287: iti69 = 1 � 669 JJ K <br /> 5, s 'a id Gen1rdj'ep e�(iRf�Qg1 than mailing address) <br /> � � <br /> �+fn�6 STOCKTON,CA 95203 <br /> Generator's Phone: (209)464-2922 <br /> 6.Transporter 1 Company Name U.S-EPA ID Number <br /> EQ INDUSTRIAL SERVICES MK 435 642 742 <br /> 7.Trsnspnrter 2 Company Name U.S.EPA iD Number <br /> 8.DosNnaled.Fadilty Name and site Address US ECOLOGY 113A FC] INC U.S.EPA ID Number <br /> 20400 LEMLEY RdAD IDD 07S-114 654 <br /> GRAND VIEW,ID 63624 <br /> FaWltyrs Phone: 80 274-1516 <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 Quantity Wt.Nol. 13.Waste Codes <br /> 1. N101 , Carbon Dioxide, 2,2,ERG 0120 001 CY 00001 P 181 <br /> 0 <br /> H <br /> LJ <br /> 4R O.UNW03,V"e FlaM,Ae W, IAA, P611, ERGs 0114 001 DF 00002 P I]MI1 D003 D005 <br /> 141 <br /> ZUN0312,YVirste Cortndges, S*1114 1 AG,PG11, ERG 0114 001 DF 00005 P 13001 D003 DOW <br /> • 141 <br /> X 4-UN3108,V*de Organic peroxide type E, solid(Dibenzo)l 001 DF 000% P D001 211 <br /> peroxide (pasta), <052%), 5.2, PGII,ERG#145 <br /> fi <br /> 14.5pe_cia Handling Instructions andAddlional n ormation <br /> 1-v1�STM131 CO2 Cylinders 2.WESTM22/Aerial Flares 3 WESTW31 SignoWSrrl Flares 4.WESTIM7 f Bentoyl Peroxide Based Loosepack <br /> Harderear[T:14.14.54772 11 <br /> 15. GENERATOR'S/OFFEROR'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 labeled/placarded,and are in all respects iryproper condition for transport according to applicable international and national governmental 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 /> GeneratoeslO foror'8 PrintedlTyped Name _ 'Signature. Month Day Yenr <br /> L,�,l_ v,i 0 0!�e,r-sr �� � --- -i I 117 11 <br /> 16-Intematlorral Shlpmenie <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/eRit: <br /> z Trarlsporler aignature(for exports only); Date leaving U.S.: <br /> 17 Tragsp riarArxnowledgment of Receipt of Ma4er10 <br /> Tfa r I Pdn ypod Name Slgnature Month Day yoar <br /> y - - <br /> TrbmpbMr2l3 itied,7yped{game Sign Mcnih Day Yea: <br /> 18.Dlacrepa y <br /> 18a.Discrepancy Indication Space 11 ❑Type j <br /> Quaff yp El C�Partial Rejection �Full Rejection <br /> Manlfesi Referenr:e Number. _ <br /> H 18b.Alternate Facility(or Generator) V.S.EPA ID Number <br /> [.7 <br /> LL Facility's Phone: <br /> w I&.S ignature of Alternate Fadirty(or Generator) -T onth Day Year <br /> a � <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ <br /> 1 H132 2 H132 3 H132 4. H132 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered-by the manifest except as noted in Item 18a <br /> Prin fTyped Name --) SlgilA , Mcnth Day Y0, <br /> EPA Form 8700-22(Rev.3-05) Previntrs editions are obsolete, DESIGNATED FACILITY GENERATOR <br />