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I Please print or type.(Form designed for use on elite(1 2-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator 11)Number 2.Page 1 of 1 3.Emergency Response Phone4.Manifest 1 ac 111 ig Number <br /> WASTE MANIFEST PAL000409953 P775772669 <br /> 5.Generator's Name and Mailing Address1 009149120 FLE <br /> Generator's Site Address(if different than Mailing address) <br /> Banfield Pet Hospital #1164 Banfield Pet Hospital#1164 <br /> 2098329373 2477 Naglee Rd 2477 NaRlee Rd <br /> Generatoes,Phone: Tracy, CA 95304 <br /> 6.Transporter 1 Company Name CA 95304 <br /> U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc <br /> 7.Transporter 2 Company Name �NS0081 110924 <br /> U.S.EPA ID Number <br /> - 8.Designated Facility NameandSite Adores <br /> U.S.EPA ID Number <br /> H855 Whitv Ruck <br /> 3 L3-d7,- r-iia e.down-,-eA----xj5fte 42-r ZvZr <br /> jrLv-613Z --%" <br /> Facility's Phone "311013ft jvr� Td <br /> -r-197 -de4 IdSO <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> waste Ke_Ti—c1nj-_ No. Type Wt./Vol. 13.Waste Codes <br /> I su'10% r-OXIC, n.o. s. 1 T <br /> 0 <br /> (Selenium, Silver), 6. 1, PS II, ERG#151 <br /> trt <br /> 2. <br /> W <br /> 3. <br /> 4. <br /> _L <br /> 14.special Handling Instructions and-Additional Information <br /> 1. 1109331(Rx Toxic Solids) <br /> 15. GENERATOR'S/OFFEROR'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 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 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 generator)is true. <br /> ne Wolerors Pante <br /> Co�l yped Name Sign7W Monffi 77a-y----7e—ar <br /> ri 16.InternationalYN 4 <br /> Shipments D import to U.S. ❑Export from U.S. Port of entry/exit- laq 105 <br /> Transporter signature(for exports only): Date leavinq U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter I Print-eWy—ped Name <br /> R- <br /> Mon ay <br /> at)hil 14arciel <br /> Transporter 2 Printed/Typed Na <br /> ign ure <br /> IT Month Day Year <br /> 18.Discrepancyc���. <br /> 18a.Discrepancy Indication Space 1:1 Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> -luu.Alternate t-aciitty(or Generator} Manifest Reference Number: <br /> U.S.EPA ID Number <br /> ul-t '-Signature utAlternate t-acifity(orGe,-.-,, <br /> eE Month Day Yaaf <br /> _19.Hazardous Waste- <br /> R"Oft Management Method Codes(J.e.,codes for hazardous waste trp:lf�f IG <br /> 2. and recycling systems) <br /> 3. a. <br /> 20. nafed <br /> Facility Owner or Operator Certification of receipt of hazardous materials oo <br /> Na(06 vered by the manifest except as noted in Rem 18a <br /> _ Suture <br /> D Da <br /> a <br /> -Foff 8 <br /> Year <br /> -22(Rev.3-05), reviOus editions are obsdlet6 <br /> ,?A <br /> RkForrn,8 <br /> n <br /> ?AFOIM'8 <br /> DESIGNATED FACILITY TO DESTINATION <br /> STATE(IF <br />