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-SK SH I Pit 232688724 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Em Res o e Pho a 4.Manifest Tracking Number <br /> als <br /> WASTE MANIFEST �AR000039� � �L 1 �P1 <br /> SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Escaiutl Vj�,,215ier -,ir&l165 Inc. <br /> 1705 Mcheivoy Ave <br /> ESCALON CA 95320-0000 <br /> ! Generators Phone: 209-552-6051 <br /> 6.TgRotterlorttpa�yNattng U.S.EPA ID Number <br /> SYSTEMS INC TB®0fd0E11; 05 <br /> 7.Transporter 2 CompanyName U.S.EPA ID Number <br /> CLEAN HAF QRS ENV SVC INC, MAD03932 250 <br /> 8.Designated Facility Name and Site Address THERMO FLUIDS INC U.S.EPA ID Number <br /> 125:33 SE CARPENTER DR <br /> CLt=:C;GAMtAS , OR 97015-8988 <br /> GROW0025197 <br /> 503-788-4616 <br /> Facility's Phone: <br /> 9a. 9b.U-S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WtNol. <br /> 1. NON—RCRA HAZARDOUS WASTE SOLID <br /> o (DRAINED/UNDRAINED USED 51L FILTCRS) - <br /> w <br /> a 2. <br /> LU <br /> c7 <br /> 3. <br /> 4. <br /> t 14.Special Handling Instructions and Add°t oval information 84573L Sl!I (''i <br /> 24H EMIERGENCY#800-468-1760—CH/SKlTFI—Contra6t retained by generator confers avency aaJ.Lnor.. <br /> 11'n i n i t i a 7 franSnn ' nr t 0 ar?r} ov- Srahcf i t uteAd itinnal t AGnnr,tprc nn rec"Pn, n),-, c hPh;x1'' <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 tabeledlplacarded,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 I am a small quantity generator)is true. <br /> Generator'slOfferoes Printedfryped Name Signature /�f p,f Month Day Year <br /> 16.International Shipments ° <br /> H ❑Import to U.S. ❑Export from U.S. Dort of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> 11-- Tran�spforter 1 Printed/Typed ame Signnaatu-r-e^- Month Day Year <br /> Tian pod 2 Prinledfryped Name /� Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection] ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> a.. Facility's Phone: <br /> Lu 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a , <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 2. <br /> b � <br /> 20.Designated FAili(y Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except 'noted in liem 18e / <br /> Printedfryped Name Signature Month Day Year <br /> i��� g � I �, 2 •�; <br /> ,..,.�( � ° �1 t.�r u 1 'l«_ 1, tea- _-/), f' <br /> EPA Form 8700-22 Rev. 2-17 Previous editions ate obsolete. / DESIGNATED FACILITYITd GENERATOR <br /> )787267b/I Lb 3 <br />