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Please print or type.{Form designed for use on elite(12 itch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 oT 3 EriWgapcy Rgxppnge. MonifestTrackIng Nurser WASTE MANIFEST CAL,00( � 8 8 Q 1 5 J J K S, Irye Nrr Gene�181Ci �¢rasa„{IldiAffV�thanmailingaddress) ATC1N01NVILLF CA*6 STOCKTON, CA 95203 Generator's Phone: Oft 464-2922 0 1�ansporrer 1 C:;:nlfanyName U.S.EPA ID Numbnf TRIAL SERVICES 642 742 7 Trar viler 2 W Company Name U.S.EPA ID Number Hs1H SYSTENED 9W 382 133 I.Designated Facility Name and Site Address US ECOLOGY IDAHO, INC- U.S.EPA ID Number 20400 LEMLEY ROAD IDD 073114 654 GRAND VIEW,IID 93Si24 acility's Phone: (NO)274-1516 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. RQ, UNl1Pt e&Fl nlmabk liquids,n.o.s.(G ere, 001 DM 00009 P 331 0001 ” o Pelmak=DistWW, 3,PGII,RO(D011),EFtG#128 U002 U164. Ut5t3- W x 2.UN1013, Carbon M , 2-2: MG#020 001 CY OQOd p 3.Non4W.,Non-RCRAHazardaus td de,Liqulld 001 OM 00015 P 141 331 4. 14.Special Handling Instructions and Additional Information 1.WESTMOM i Fftww W Lipids;1 D9f l;,1 07,DOW,0010,D011,D01119,D027,DM 2. WESTh013/CO2 C:,fii o&xs 31 WF1,4TW6 NON HAZARDOUS UGUID [Y:1114,14101170.Ill V 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Tully and accurately described above by the proper shipping name,and are classified,packaged, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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 quantrly germNor)is true. Gerreralor slOfferafS PdntedlTyged Name Slgnalure o Month pay Year }� �A , '\ • � r� X 1 �;�{�v _ U5 ill 18 Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of enlrylexil: z Transporter signature(for exports only): Data[raving U.S.: 17.Transporter kknawladgment of Recelpt of Mota0ls LU �2 Tronepodarr I Printar),r•ryped Name Signature Month Dsy Year QronaporWg dnledrTpod Narrre sralum Month Day Year 18-VIscrgpancy _ 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rel ection Manifest Raference Number I8b.Altamale Facility(or Generator) U.S.EPA ID Number J_ V LL Faclitys Phone: 1�1UA 18c,Slgosature of Alternate Facility(or Generalor) Month Day Year x 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1 2, 3. A H141 NONE 21),Designated Facility Owner nr.Op"tgr.Certification of receipt of hazardous materials covered by the rnani(o except as noted in Item 18a - NnPaype arm3 r Month Day YQar C' EPA)arm X700.72(Rev.3.05) Previous editions are vhsolate. ; DESIGNTE FACILITY TO GENERATOR