DSHW-2025-001472

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Utah State ffilv"Cf
Envt ronmental l""iealth
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BUREAU .ffi"$ ',AND HAZARDoUS WASTE
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THAI{K YOU,
Please print or type with ELITE type (12 charact inch)in the unshaded areas only
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GS/ No. O246-EPA-OT
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States -Environmental flqtection AgencyWashington, DC 20460 e t
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F i li n s Notif ic at i on before eomplet i nsthis Iorm. The inforrnation reo'uesteil
Iqrp- is- required by lgw (Section
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A. 'Hazardou,s Wdste Activitv B..,,[i|.tOd,:,,, Oil : FuO,[ ActiuitiBs
El I i. G,gn*ratsr ' ' t o. Less than I,OOO rI/*o.
E Z. Transporter
fJ S. Treater,/Storer,/DisBoser
E S. Market or Burn Hazardous Waste Fuel
(enter 'X' and mark appropriate boxes betow)
E ". Generator Marketing to Burner
E u. other Marketer
E .. Burner
fr6. Off-Specification Used Oil Fuel
fJ ,. Generator Marketing to Burner
t-lLI c. Burner
E Z. Specification Used Oil Fuel Marke ter {or On site Eurner)
Who First Claims the Oil Meets the Specification
Vl'].Wastefu,o!Bwfiing:T-ypeofCombustionDevicelenter'x'iial!:wprwliqrq&orartorhi r'tCt1q,q.if,w@gsltgiae"yU*itlawhich hazardous rryaele luel or off-specification usgd.oit'fuel is burncd..Se inxruabns lw delinitions ol catnfu.tstion dovices.)
n a. utitity Boiter E e. lndustrial Boiler fJ c, lndustriat Furnace
Vlll:' Msde o{ Trgnsoo,itb$on l anmorters:onlv'- ett:ter X' inlh&:esoiooridte:,bcix{as}
E a, Air, t] E. n,air f] C. Highway 'fJ o. water f]'E, other (specify)
EI(a. Fi rst Notif ication I B. Subsequent Notification (complete item C)
:if:ication of hazardous wa,ste activitv or :,d subsequ€,t'ltin the spaee provided below , ::
C. l"stallrtio,t's EPA lD Nr*b*
Continue on reverseEPA Form 87OO-12 (Rev. 1 1-85) Previous edition is obsolete.-ZtA ocr 23
lD or Official U,$e Only
ESGrlOtiOil of llazard,:ous Wastes continu 'iom frAnt,
A, !'laffifdous UYactce {rom Bonspcifoc Sourrcs,.Ente.rthetoqr-digit.numbor frorn zl0 CFRPart 251.31 for esah listed hazardous waote' lrom nonspecific sources your installation handles. Us6 additioflal sheers if neco€sary.
specific sources your installetion handles. Use additional sheets if necessary.
pitals, or medicat and reeearch l€borstoriea-your installation handles, Use additisnal sheets if n€@ssary.
E. Clraractedaicr of Nonlictpdr:rHszardouc ll,Y$les: Ma* X' in thE @es,oorogponding Sitthe characterisuc6 of no!,isted hazardou$ waslesyour installation handles. /See 4O CFR Parts 261 .21 - 26r.24)
>EI,.',l. lgnitable
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obtaining the intarmai::lbn, t believe ihat 1hs1,sub@d infAtmaiian i.s tJute, accurate, and complate.l am aware that
l,fFlfqar$,s,{gwifraa,t''p&;1trs"far subtnlittifgttalsa',iatatttastio&iacludingthcpassibility af lineand:'imprisonment.
Name and Official Title (type or print)
JERRY BILANZICH i MGR.
Date Signed
A Form 87OO-12lRev. 11-85) Reverse
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,.t7-31-86
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UNIFORM HAZARDOUS
WASTE MANIFEST
1. Generator's US EPA lD No. Manifest Document No.)(N 2. Page 1
of
lnformation in the shaded areas
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3.Generato/s Name and Mailing Address
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A! $[afe,Manifest Decument Number
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5.Transporter 1 Company Name
E XoT<K, ]Fuc,
6.
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US EPA lD Number c. srare Transporters lD urD oq3{ lt rl
D. Transporte/s Phone Ra . g47-q (obA
7. Transporler 2 Company Name 8. US EPA lD Number
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iE.,,i,$tale TranSportefs lDIf fO D8 4- ll q* I q I
F., Transportels Phone *6 l- 513-4662
9.Designated Facility Name and Site Address
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10.US EPA lD Number
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$tate Facility's lD'," :: :
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1 1 . US DOT Description (lncluding Proper Shipping Name, Hazard Class and lD Numbe|
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12, Containers
No. I rrot
13.Total
Quantity
14.
Unit
WWoI
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Waste No.f
a.;{nz* RDot*5 UJAIte, Lt %Lrt l>
DPed+ S[oDDftfD Se\ueof
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15. Special Handling lnstructions and Additional lnformation
16.GENERATOR'S CEFf,IFICATION: I hereby declare that tho contonts of this consignment are fully and accurately described abov6 by prop€r
shipping name and are classified,.packed, marked, and labeled, and are in all respects in proper condition lor transport by highway according
to applicable international and national government regulations.
Unless I am a small quantity generator who has been exempted by statute or regulation from the duty to make a waste minimization ceitification
undor Section 3002(b) ol RCRA, I also certify that I have a program in place to reduce the volume ancl toxicity of waste generated to the degree
I have determined to bo economically practicabl€ and I have selected the method ol tr€atment, storaga, or disposal currently available to me
which minimizes the present and tuture threat to human health and the environment.
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Printedfl'yped Name Signature Month Day YearX Xt rr
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17. Transporter 1 Acknowledgement of Receipt of Materials
Printedfl'yped Name Signature Month Day Yearltr
18. Transporter 2 Acknowledgement of Receipt of Materials
Printedfl-yped Name Signature Month Day Yeartlr
FAc
IL
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Y
19. Discrepancy lndication Space
20. Facility Owner or Operator: Certilication o, receipt of hazardous materials covered by this manifest except as notod in ltem 19.
Printed/Typed Name Signature Month Day Yearllr