Laserfiche WebLink
f <br /> -p x <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ER Form AppfoVed.,plNB No.2050-0039UI!MFORM S 1•gator ID Number 2.Page 3.Emergency Response Phase 4.Manifest Tracking Number <br /> WASTE MANIFEST CARO 229732 8009246804 1 0101770,74 F L E <br /> 5.Generators Name and Mailing Address Generator's Site Address(ff different than mailing address) <br /> CVS #3908 CVS#03908 <br /> 2098362300 1885 West 11th Street 1885 West 11th Street <br /> Generator's Phone: Tracy, CA 95376 Tracy, CA 95376 <br /> 6.Transporter 1 Company Name U.S.EPA I Number <br /> Stericycle Specialty Waste Solvations Inc MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> "l " S 4'4L `s Ste 3 3 <br /> 8.Designated Facility Name and Site Address 9t e r i cy r l e, Inc. U.S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, I1, 46241 <br /> Facititys Phone: 3175245617 INN 0110197 <br /> ga 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(d any)) No. Type Qua" wt./\". <br /> x X 1.UN2810, Waste Toxic, liquids, organic, n.o. s. 1 CF 00001 P 31 :1 UO3 <br /> o (Chloral Hydrate), 6. 1, PG II, ERG#153 , <br /> a 2. <br /> UA <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information 1. 1010 52(R X Toxic L.d4uids) <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quentity generator)o(b) 'f I am a small quantity generator)is true. <br /> GeeneratWes/ erbes 'n yped Name Month Day Year <br /> 01 21 2017 <br /> 16.lnle is <br /> ❑import w U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter signature fore ad : Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> 12 Transporter 1 PrkhtedfTyped Name ay Year <br /> O Jeff Hamilton 1 01 21 2017 <br /> rn <br /> ZTransporter 2 Printed/Typed Name 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 /> Q <br /> n+- Petals 's Phone: <br /> C3 18c.Signature of Altemate Facility(or Generate) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous waste Repot Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1 2. 3. 4. <br /> AbA <br /> - I <br /> 20.Designated Facility 2M or Operator:Certification of receipt of hazardous materials covered by the rrman' t exceogs noted in Item 18a <br /> vnntedrryped Names Ci:5:k <br /> Month Day Year <br /> atui i161 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> A, —'Pr 1 r^v f Ara?7OV0 M r>T:rr,m� - -I r nrnn..: .— <br />