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Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />11111111 Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-P (R/ 3-05) Previous editions are obsolete. <br />,'/ /ESSIGN.ATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />'.Genea'o'ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. Mairilf&M TwAin2WASTE <br />MANIFEST <br />I <br />I - - I <br />677��77P,-,Eq 1 008F)"8,0359 <br />F L E <br />- <br />S. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />L <br />'la 11 a r- IS e n e- a I # 143531, D * I I — !- 116; a n� P il ;� , <br />2092-7513-77 915 E YOSEMITE AVE tea?5 E t0 SE. Fri 1 T E AV E <br />GemqaWs Phone:14ANIECA. CA Tsai`: -55; <br />6. Trarqponar 1 Company Name U.S. EPA ID Number <br />Stericycle S13ecialty Waste Solutiorts Inc mi,4sowmai I 0,;Pa <br />I- Transporter 2 Company Name U S. EPA 10 Number <br />8 Designated Facility Name and Site AddiressU.S. EPA ID Number <br />Genet -al Enyirnen <br />omt,-41 Mint, LLI' <br />11855 White Rock Road <br />Rancho Cordova. CA 95742 <br />FacjliysPhone; 916351098@ CAD2&A �3 <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (d any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />'Non RCRA hazardous waste. liquid (Consuvie)- <br />I <br />DF <br />Vqo 4 1 <br />Ila <br />P <br />331 <br />Products), <br />2. <br />6 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 1.110524(Non—RCRA Liquid Waste (CA Only) — Loosepack) <br />15. GENERATOR'S10FIFEROR'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 labeWIplacarded , and are in all respects in proper condition for transport according to applicable intemational 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 40CFR 262.27(a) (if I am a large quantity generator) o <br />, I am a small quantit��e tor) is we. <br />Mr% I re( Month Day Year <br />(ie <br />1 16 W17 <br />1.Intern dtiorfalShipments <br />FlImport to U.S f, U.S. Port of entry/exit--� <br />Z <br />-. <br />Transporter signature (for exports ontv): Date leaving U.S./ <br />E <br />UJI <br />17 T ransporter Acknowledgment of Receipt of Materials 1 7 <br />7 <br />12 <br />Transporter 1 Printedrryped NameMonth Day Year <br />0 <br />W <br />Anthony Mack T��Iz" I I 11 1 1601? <br />Transporter 2 PdntedrFyped Name Sign Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑Type El Residue ElPartial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b Alternate Facility (or Generator) U S. EPA ID Number <br />:3 <br />LL <br />Ca <br />Y�at­,re Phone. <br />Uj <br />18,. Alternate Facility (or Generator) Month Day Year <br />co <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Uj <br />In <br />1 2. <br />20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />FT,—WfTypdNa.e Signature Month Day Year <br />ezrr 14 � Z? t" P-6 eu - , L- I i 11 13a J7 <br />EPA Form 8700-P (R/ 3-05) Previous editions are obsolete. <br />,'/ /ESSIGN.ATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />