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Please print or type.(Form designed for use on elite(12 pitch)typewriter.) r. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator to Number 2.Page 1 of 3.E cy Response PMM 4.Manifest Tracking Number <br /> WASTE MANIFEST larA008553729 FL E <br /> 5.Generator's Name and Mailing Address Gems Site Address(if different dark mailing address) <br /> CVS #3908 CVS#03908 <br /> 2098362300 1885 West 11th Street 1885 West 11th Street <br /> Generator's Phone: Tracy, CA 25 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steric cle Si3ecialty Waste Solutions Inc <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> JrN S {/IaI 7b[��7✓ <br /> 8.Designated Facility me and Site Address St e r i c y c l e, Inc. U.S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> Facii ty's Phone:3175245617 I RIROOfl!110197 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) <br /> No. .Type ' Quantity WtNoi. 13.Waste Codes <br /> o X 1URI3248, Waste medicine, liquid, flammable, 1 CE 00001 Fr 311 D001 <br /> a toxic, n. o. s. (Alcohol), 3 6. 1, PG II, ERG# <br /> z 2. <br /> w <br /> ca <br /> 3. , <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 102966(PX State Regulated) <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully acrd accurately described above by the proper shipping name,and are classified,packager!, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and rational 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 /> 1 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' O feror's PrintedlTyped Name Month Day Year <br /> U <br /> 16.Internationa Shipments <br /> i~ ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> ? <br /> Transporter signalunelfore its only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receiptof Materials <br /> Ij Transporter 1 Pdnted(fy*Name Signature on ay year <br /> Qno Isidro Martine, �. t�J6. ,. 28 201' <br /> Transporter 2 P'n Narru Monthy Year <br /> tW- <br /> 18.Discrepancy I Via In <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Referer <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> 4 <br /> �- Facili 's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> W 1 g.Hazardous Waste Report Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal,and m systems) <br /> l ems <br /> ) <br /> 1. <br /> 2. 3. <br /> 4. <br /> 20.Designs, Facili r or Operator:Certification of receipt of hazardous materials covered by the!7M <br /> 8a <br /> Prnted/Typed , <br /> Monfh Day Year <br /> EPA Form 8700-22(Rev.3-05) .evious editions are obsolete. x ED FAC,?1.t,, OESTINAPON S 7ATE(IF REQUIRED) <br /> 8700-22_12v3 {;?L20090t641 988 6 04',3877312 )ri Tff� ='a i ^nnerr.n t <br />