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Please tint or e. F designed f - 111111111111111 <br /> p type.(Form des g d or use on elite(12 pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest T Nrc W <br /> WASTE MANIFEST till 1 IAA 7 7 E _; ; 008680359 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> �^^ ;°r I i nt ne; l #, 5 L+ :1 i=r ar t, j <br /> _ 5 i# 4: ; <br /> 115 E YOSEMITE AVE r4 5 c Y 0 SE.al T AV <br /> w� GerreraWsPhone: 14ANTECA. CR <br /> 6.Trarqioner 1 Company Name U.S.EPA ID Number <br /> l tericycle Soecialty Waste Solutions Inc I mi,4 wmai I. ,;Pa <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 1 <br /> 8 Designated Facility Name and Site Addressr U.S.EPA ID Number <br /> L7-net'a1 Enyir'Di'ment�l tint, LLI' <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95-142 <br /> Facili Phone: 915351098O <br /> 9a 9b•U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Godes <br /> HM and Packing Group('d any)) <br /> No. Type Quantity Wl.Nol. <br /> 'Non RCRA hazardous waste. liquid (Consuvie)- 1 DF VWi1a P 331 <br /> Products), <br /> z 2. <br /> 6 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1, 110524(No n-RCRA Liquid Waste (CA Only) — L o o s B pac k) <br /> 15. GENERATOR'S10FFEROR'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 intemafional and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerlify 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 <br /> (iein 400CCF(R�262.27(a)(if I am a large quantity generator)o I am a small quanti ne tor)is we. <br /> Day Year <br /> tors g re( <br /> e IMI', 1 16 W17 <br /> —� 1 InterinditiorfalShipmenTs <br /> ❑ <br /> Z Import to U.S ❑Export fr U.S. Port of entrylexi t _ <br /> Transporter signature(for exports ontv): Date leaving U.S./ l <br /> W 17.Transporter Acknowledgment of Receipt of Materials 7 f f <br /> Transporter 1 PrintedlTyped Name g re Month Day Year <br /> CL Anthony Magi ( 11 16 017 <br /> QTransporter 2 Printedfryped Name Signatme Month Uay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U S.EPA ID Number <br /> J <br /> U <br /> LL Faals Phone. 1 <br /> W 18,.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> co 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj <br /> 1 l J 1 2. 3 4 <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Nnled[Typed Name Signature Month Day Year <br /> e-or U �/ Z?mdsI r I Ci r 111110117 <br /> EPA Form 8700 (R 3-05) Previous editions are obsolete. ESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />