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Please print or type.(Form designed for use on elite(12-pitch)"writer.) ERTI N Form Approved,OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1" 2.r I of I 3,&Xg4gM Phone 14.Manifeat Trawng Number
<br /> WASTE MANIFEST 010176084 F L E
<br /> 5.Generators Name and ailing Generator's Site Address(If different than mallingaddress)
<br /> I
<br /> S #3908 CVS#0390
<br /> 2098362300 1885 West 11th Street 1885 West 11th Street
<br /> Genemlor's Phone: Tracy, CA 95376 Tracy, CA 95376
<br /> 6.T677s[g-ftr I M—�y Name U.S.EPA ID Number
<br /> Stericycle Specialty Waste Solutions Inc MNS000110924
<br /> 7.Transporter 2tompany NameU.S.EPA ID Number
<br /> Ale 114of, A
<br /> " Z I" IwAe?/_a
<br /> 8.Design M Facuity Name and SiteAddress MST Century I: , I-Lt- U.S.EPA ID Number
<br /> 2095 Newlands Dr. East
<br /> Fernley, NV 89408
<br /> FacWs Phone: 7755752760 NVD9 0895338
<br /> ga, 9b.U.S.DOT Descripfion(including Proper Shipping Name,Hazard Class,to Number, 10.Containers 111.Total 12.Unit 13.Waste Codes
<br /> HM and Packing Group(it ary)) No. Type Quantity wtivol.
<br /> --r-
<br /> 1:bW3M4 WaSte RusIllue Cast Convalfila, ffoM --P7— '511 ptotal
<br /> 0 Medicine, solid, toxic, n.o. s. (Warfarin),
<br /> 6. 1, PG 11, ERG#151
<br /> X 2.UN2811, Waste Toxic solids, organic, n.o.s. I CF 00002 P 311 D007 DOI@
<br /> Uj
<br /> (Chromium, Selenium), 6. 1, PG II, ERG#154
<br /> -%-Tumi-9-93, waste Flammaole liquids, n.o.s. 1 DF 00092 P 311 DO01
<br /> (Alcohol), 3, PG 111, ERG#128
<br /> 4.1.11111'=14, Waste Flammo liquii3s, n. o. s. 1 00049 P 214 DOOI U002
<br /> (Alcohols, Acetone), 3, PG 11, ERG#128
<br /> 14.Special Handling Instructions and Additional Information 1. 101079(Residue weight does not exceed 0.0436 lbs) CNT:19 2.
<br /> 100196(RX Toxic Solids ) 3. 111250(CA Liquid Pharmaceuticals) 4. 100198(Flammable Liquids)
<br /> 15. GENERATOMSfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper slipping name,and are classffitxl,packaged,
<br /> marked and labeWplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.11'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 /> I certify that waste mWizatio ti den
<br /> ,p.� filied 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 /> Gerye b Spature Month M-Y--Te-a—r
<br /> 021 20120111
<br /> 116.Internation-al Shipirents U
<br /> 0 Import 0 U.S. El Export from U.S. Port of entry/exit:
<br /> I22Lporler signature for ex its on : Date leavi2p U.S.:
<br /> 17.Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 PrintedfTyped Name Month My Ve-ar
<br /> Phil Marciel A .-I 021 2012018
<br /> CZ* Transporter 2 Printedfryped Name Signaturam.-'----wT Morm usy Year
<br /> ,7 1 24o,"
<br /> 18.Discrepancy
<br /> Ise.Discrepancy Indication Space Quantity [:]Type 0 Residue El Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number.
<br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number
<br /> u- Facility's Phone:
<br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year
<br /> Z
<br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling sy")
<br /> Uj 3. 14.
<br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous malerials covered as noted in Item 118a
<br /> PrintedlTyped Name Signature Month Day Year
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ES TED FACILITY TO DE ON STATE(IF REQUIRED)
<br /> 8700-22 12v3 CAL200130641 58876 041049458 M SD022018,
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