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I Ie S punt <br /> -ortype.(Porn designed far use on elite(12-pitch)typewrriter.) IrR$- _ , Form App a ed.OMB No.2050.0039 <br /> NF1?RM HAL0.RDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST IaR2732 ` 8�t�924684�4 010170083 FLE <br /> 5.Generators Name and Mailing Address Generators Site Address('d different than mailing address) <br /> CVS , CV-C#03908 <br /> 20983,2300 1885 gest 11th Street 1885 gest 11th Street <br /> Generators Phone: Tracv. CA 95376 Tracy, Ce 95376 <br /> .Transporter I company Name U.S.EPA ID Number <br /> 1 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 5t e r i c y c 1 e, Inc. U.S.EPA ID Number <br /> . 2678 Executive Drive <br /> Indianapolis, IN 46241 <br /> Fadlry's Phone: 2 C1 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Cafes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Aroi. <br /> rx X 1'UN3248, Waste Medicine liquid, flammable 1 Cr ®t80181 P 311 I? 1 <br /> ro toxic, n. o. s. iAlcohol ,livid,1, PG-3Ii, E�tC-# <br /> 131 <br /> Uj <br /> LU 2. <br /> _ f <br /> 3. <br /> 4. <br /> 14.Special Handling In <br /> stnutiorhhs and Additional W-oration 1. l0E-':J1bb(HXState Regulated) <br /> 15. GENERATOWSIOFFEROR'S CER71FICATION: 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 iatemational and nationalvernmental <br /> 90 regrtations:lt exportshkrment and I am the Pdrhhary <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 quantity generator)or(b)(if I am a small quantity enerator)is true. <br /> to s Printed/Typed Name Signature _ Monti <br /> Day ear <br /> ti 1 t1 0e 20 201 <br /> J 16.International Shipments <br /> It- ❑import to U.S. ❑Export from U. . Port of entrylexit <br /> Z <br /> Transporter signature for exports on1 : Date leaving U.S.: <br /> W 17.TransponerAcknowledgment of Receipt of Materials <br /> Transporter 1 <br /> PnName gMonth <br /> -- Y Year <br /> O Phi 4e1 <br /> L42 240 -201 <br /> ZTransporter 2 PrinteRyped Name7 natureMonth Day- Ye <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator Manifest Reference Number. <br /> ) U.S.EPA ID Number <br /> a <br /> wFadii s Phone: <br /> W, 165. Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 <br /> 2 <br /> W19.Hazardous Waste Report Management Meted Codes(i.e.,codes for hazardous waste trestaent,disposal,and recycling systems) <br /> 01 <br /> 20.Designated Facility Owner or Operator:WcafiDn of receipt of hazardous materials covered by manifes##pt as noted in Item 1 Ba <br /> Pdn Name Month NY, Y <br /> ew <br /> " EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 870171-2212V3 CAl.20090641 98876 041049458 M <br />