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)g <br /> t Form Appftfved.QMB No.2050-Op r <br /> t carrpe:(Form designed for use on r Nle(12-pitch)typeWnter.) 2.Page 1 of 3.Emergency Respatsa Phone 4.Manifest Tracking umber <br /> RM HAZARDOUS 1.Generator ID Number ®®O C t� +�C/� <br /> TE MANIFEST CAR00022973 8009`x+' S80�F O G7 L L a]'t <br /> s;°- eretor s Name_and Mailing Address Generator s Site Address(g different than mailing address} <br /> a <br /> CVS #3908 <br /> i98362300 885 des} 11th 'treet 1885 West 11th Street � <br /> Ger YdtorsPtigrle: <br /> Tracy, CA _ {r <br /> Trac;a [A 953 r 6 <br /> U.S.EPA ID Number <br /> ransporter 1 Compan y Nameat�0@110"}2+ <br /> LtE*"cc '�12 �] £tC2 t'p? f =do- „,i�lt�ti ':1= Inc <br /> U.S.EPA ID Number <br /> 7,1Fansporter 2 Company Name <br /> I / <br /> 8.E>eskjrraled facility Name and Site Address 9t e r i c r c 1 e j D U.S.EPA ID Number <br /> 670 kxec_;*'s;.;M Drive <br /> Indianapn,lj.s 7r•) 46241 <br /> Facows Phone: .?1-7'=E4g" <br /> 9b,U.S.DOT Description(including ProperShipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 98. <br /> HM <br /> and Packing Group(if any)) No. Type Quantity WtAV. <br /> X 1 UN3248 'Waste Medicine, l a ,td, flammable 1 GI uit�t�1t4r1 31j Lih�; <br /> o taxis. n. (Alcohal:' P6 _1a ERG# <br /> 131 <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> I <br /> 14.Special Handling Instructions and Additional Information :y 1 t?i_'_;p, (q)( 9tate Re rx ri'i at ed) <br /> i <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and mately described above by the proper shipping name,and are classified,packaged. <br /> marked and labelediplacarded,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 EPAAcknowtedgment 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 a small quantity ?tor)is true. n a Year <br /> Generator Offero's Printed/Typed Name tine <br /> is # �� <br /> -.,r 16.Intemadonal Shipments ❑Import U.S. ❑ . . of'"mitt <br /> Z <br /> re for rls Date tea' U.S.: <br /> Trams orter s' lu <br /> LM 17.Transporter Acknowledgment of Receipt of n ay ear <br /> 12 Transporter1 Priniedfryped Name <br /> o1c:1 1 <br /> Phil MarcielYear <br /> Trarorter 2 Print` Name gnature <br /> a• o <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity <br /> ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> aADO lntier,.,.,he. <br /> J <br /> Facati 's Phone: Month Day <br /> 18C.Signature of Altemate Facikity(o Generator) <br /> 19 HazarrteUs Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,clsposal,and recycling systems)in . 3. 4 <br /> 0 <br /> 2tl.0esi�t r or Operator.Certification of eipt of hazardous materials covered by the me' ce s noted in Item tsa <br /> to <br /> Mmexv 1, <br /> farm 8100" 2( ev.3 05) Previous editions are obsolete. DESIG14ATE�FA ILITY TO DESTINATION STATE SIF REt�I <br />