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i <br /> I <br /> NONHAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST '-'s- <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Caltrans Dist 10(Stockton MTCE) 1604 South 5 9t <br /> 1975 East Charter Wa)r <br /> Stockton,CA 95201 USA Stockton,CA 95206 USA <br /> Generator's Phone: <br /> 6.Transporter 1 Company am" U.S.EPA ID Number <br /> DILLARD EMARONMENTAL SERVICES CAM82523433 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Steacycle <br /> 11875 White Rock Road <br /> Rancho Cordon,CA 95742 USA <br /> a <br /> Facili s Phone: 6 <br /> t 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Ouantity WtNol. 1; <br /> 0 1. Non•Hazaidous Mateflal Waste Sold(Sharps) P <br /> W 2. <br /> I7 <br /> 3. <br /> 4. <br /> 13.Special Handing Instructions and Additional Information <br /> Dillard V3720.001 <br /> ' x3� <br /> 14.GENERATOR'S1OFFEROR'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. <br /> Generators/Offeror's Printed/Typed Name ig ture Month Day Year , <br /> S -ti +►mac-- 2g l <br /> 15.International Shipments <br /> ❑Import to U.S. ❑Expert from U.S. Pon of entry/exit: <br /> Transporter Si nature for exports only): Date leaving U.S.: <br /> cc 16.Transpo–Vtocknowledgment of Receipt of Materials <br /> w <br /> —Trans p Printed/T a Sign Month Day Year <br /> t7 / gr <br /> a v `� <br /> 5' < Transporter 2 nnted/Typed Name Signature Month gay Year <br /> ccc <br /> 17.Discrepancy r2 <br /> 17a.Discrepancy Indication Space <br /> ❑Quanity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> F 17b,Alternate Facility(or Generator) U.S.EPA ID Number y <br /> U <br /> L4. Facility's Phone: :. <br /> " w 17c.Signature of Alternate Facility(or Generator) Month Day Year T,,, <br /> Z <br /> C7 �. <br /> rn <br /> D y. <br /> 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a ny <br /> { Printedrryped Name Signature Month Day Year <br /> 169-BLC-0 5 11977(Rev.9/09) DESIGNA T ED FACILITY TO GENERATOR <br />