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RECEIVED 12/6/2018 <br /> Pleaseter. EJ :., _ <br /> printf oftype..(F .tips for use on elite(12 )types ) Form Approved.OMB No.20WM39 <br /> UNMsM HA tI �U3ErAR01101229732 <br /> .Generator f Number 2AMGener"s <br /> 4.Mnht T Number800924604 011434 <br /> 101 FLE <br /> ( than ma" ) <br /> v cup #3WB ct)s#03908 . <br /> 1885 gest lith Street 1885 West ilth Street <br /> Tracy, . CA 95376 Tracy, CA 95376 <br /> Company Name <br /> U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 2 Company Narrre U.S.EPA ID Number <br /> asfidy Name ark lte Address Stericycle, Inc. U.S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> F P : 3175245617 INR000110197 <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Grote(d any)) No. Type Quantity wtivol. 13.Waste Codes <br /> &-..X . 1UN. 48, Waste Medicine, liquid, flaeeable, i CF 00002 P 311 D001 <br /> toxic, n. o. s. (Alcohol), 3 E. 1, PG II, ERG# <br /> 131: <br /> z 2. <br /> w <br /> ra <br /> 3. <br /> 4. <br /> 14.Special Hmulting instructions and Additional information 1. 102966(RX State Regulated) <br /> 15. GENERATORWFFEROR'S CERTIMATION:I hereby declare that the contents of this consilimment are Arty and aawrately described above by the proper shipping name,and are classf ed,packaged, <br /> marred and labeledirplacarded,and are at all respects in proper condition for transport according to applicable International and nations governmentall regulations.If export shipment and I am the Primary <br /> Exporter I certify that the contents of this consigner condemn to the terms of the abdied EPAAckmnwledgment of Conisent. <br /> I certify that the waste minimization stahnnent Idengled in 40 CFR 28227(a)(if I am a large quantity )or(b)(if I am a smiall quantity to)is We. <br /> GeneraWskIlems Printedirryped Name n , Month Day ear <br /> `,• ; �r L _� - — 071 05 201 <br /> 16.intern Ship=hts ❑i S. <br /> ❑E pot from U.S. Pat 61 <br /> z <br /> Transporter signature(for 'ex only): Date l ing U.S <br /> 17.Trmsporler Admowledgmerd of Receipt of Materials <br /> LU <br /> ji Transporter 1 Printed/Typed Name Signature Month y Year <br /> Isidro Martinez " -- 071 05 201 <br /> z T 2 Printeclayped Name to <br /> Month� /ay Yew <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Rewdue ❑Partial Rejection ❑Fri Rejection <br /> ! "iZEIVEDk+anifest Reference Number <br /> 18b. Facility(or Generator) c U.S.EPA ID Nurnber <br /> V <br /> ul Fadti s Pfwrhe: <br /> A 'cc.Slgnahre of Altemate Facility(o ) <br /> R fTH' PPART E )i Month Day Year <br /> 19.Hazardous waste Report Management Method Codas(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> • �' 2, 3. 4. <br /> �estghafed Fac�ity Owner o Operator:Certification of recent of hazardous matertsts oo�red by dre exe�rdamn 1� <br /> 700.22 ev.3-05} Previous editions are otu�ete. ATED FA altlTY T°�DESTINATION STATE{IF REQUIRED) <br /> W 2 12v3 CAL20IB90641 58876 041143430 M PD070518 SD070516 <br />