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Please print or lype. Form-Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number ,:.: 2.Pa 1 of i ETiny e� Pflo�ra 4.Manifest Track lns NGmber ` <br /> WASTE MANIFEST CAL,000 287 469 1 f�jj33iiff 10198,6 5 935 JJK <br /> 5.Gammior's Name snd Mallin ddreas Generator's Site Address(if different than mailing address) <br /> 5 0� TR �IDS �LIVE 1$10I�l:d AVE <br /> WATSONVILLE, CA 95076 STOCKTON, CA 95203 <br /> Generator's Phone: L209)-464-2922 <br /> 5.Transporter 1 Company Name U.5-EPA 10 Numb9r-•- <br /> E0 INDUSTRIAL SERVICES MIK 4S5 642 742 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> ®ED ROCK INC. DSA TSMTCO MOD 095 038 998 <br /> 8.Designated Facility Name and Site Address US ECOLOGY TULSA, INC. U.S.EPA ID Number <br /> 2700 South 25th West Avenue OKD 000 402 396 <br /> TULSA,OK 74107 <br /> Facility's Phone: (91 0) 582-9595 <br /> 9a, 9b.U.S.DOT Descriptioli(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit <br /> HM and Packing Group(if ak No Type Quantity Wt.Nol. 13.Waste Codes <br /> X 1- kA1325,V"*Fusee,4.1, PG 11, ERG#133 001 DF 00014 P Q001 141 <br /> 0 <br /> F <br /> d <br /> O.' <br /> Lu X 2. UN 1044, Fire Extinguisher, 2.2,ERG*126 001 CY 00003 P <br /> L9 <br /> 1$1 <br /> i <br /> 3. <br /> 4. — <br /> 1H <br /> 14.S pi Handling Instructions and Additional Information <br /> 1. ST1�11 I'1MESTMII-Flams wfth Suitch Top 2.\NESTMI4 I WESTM14-FIRE EXTINGUISHERS WIOUT HALOGENS[1•:14.14.67238.4] <br /> A <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 labeled/placarded,and are in all respects in proper 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 l am_a small quantity generator)is true. <br /> ator'slOfferor's Printedr typed Name `Signa'ture�, .'Jil IVIMX I IF PR OIDU C 15 1 Month Day Year <br /> (� r ►'� n n C. .< I�\ ��.. � 1 041 251 19 <br /> 16.International Shipments <br /> ❑Import to U.S. CI Export from U.S. Porta rylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tq rter 1 PrirttedlTypad Name `�Sig`naalhr J Monb4 Dab Yqa <br /> VIA <br /> T spotter 2 Prinied(fye __ S re Month Day Year <br /> ' 1 +too �-(}-a � <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantic Type Quantity ❑ yp ❑Residue El Partial Rejection ❑Full Rejection <br /> Manliest Reference Number <br /> 18b AlteroAte Facility(or Generator) U.S.EPA ID Num`er <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z H141 Ned tf� <br /> 55 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU G 1, 2. 3 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinladfTypedIke _ Signetum - Month Day Year <br /> EPA Form 8700-22(Rev.12-17) PfeVlo seditionsareotisolele. DESIGNATED FACILITYTO GENERATOR <br /> f <br />