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d.OMB No.2050-0039 _ I Form Approve y RI d� -► Please print or type. E 4.ManifestTrackin Number R1 1.Generator ID Number 2.Page 1 of&;ertolsSlie eResponse Phone 014 0 5 8 2 8 F L E UNIFORM HAZARDOUS CAR000307777 577-2669 WASTE MANIFEST N C Address(if different than mailing address) N 5.Generator's Name and Mailing Address Wa 1 g r e e n#15398 Walgreen #15398 660 West March Lane (209) 478-0891 660 W March Ln Stockton, CA 9507-6200 Generator's Phone: Stockton, GA 9507-600 U.S.EPA ID Number 6.Transporter 1 Company Name MNS000110924 Stericycle Specialty Waste SOlr_ItlOns Inc :PAID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Nameand Site Address General Environmetal Mgt, LLC I 11855 White Rock Road Rancho Cordova, CA 95742 CAD980884183 Facility's Phone:9163510980 10.Containers 11.Total 12.Unit 13.Waste Codes 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity Wt.Nol. HM and Packing Group(if any)) X UN2810, Waste Toxic, liquids, organic, n. o. S. 1 DM 00026 F' X11 D005°D022 (Barium, M-Cresol), 6. 1, PG II, ERG#153 f- D024; U058':U 188 1 CF 00001 F' 11 F'001 Z X UN3249, Waste Residue Last Contained, Medicine, solid, toxic, n. o. s. {Warfarin), 6. i PG II ERG#151 CF 00004 F' 311 D007 D010 X UN2811, Waste Toxic solids, organic, n. o. s. 1 (Chromium, Selenium), 6. 1, RG II, ERG#154 t � X UN1950, Waste Aerosols, [flammable, (each not 1 CF 00008 F' s31 D001 exceeding 1 L capacity)] 2. 1, ERG#126 ------------ 14.Special Handling Instructions and Additional Information 1,7409{RX Toxic Liquids)--2 101089(Gen. 'Status Determination Excludes Container Wt. ) CNT:30 3. 101018{Taxic Solids) 4.244E{Aerosols, Flammable) 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,aryl are classified,packaged, in and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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.Sig atuMonth Day Year r ner tor'IOfferor's PrintedlTyped Name � 071 1112021 16.International Shipm s Import to U.S. ❑Export from U.S. Port of entry/exit: Date leaving U.S.: ? Transporter signature(for exports only): W 17.Transporter Acknowledgment of Receipt of MaterialsLU Signature Month Day Year Transporter 1 Printed Typed Name 07T 1 1 202 a Jesus A Marquez Orte a Month Day Year Z Transporter 2 Printed/Typed Name 18.Discrepancy 18a.Discrepancy Indication Space Quantity El Type El Residue ❑Partial Rejection Full Rejection Manifest Reference Number: U.S.EPA ID Number 181b.Alternate Facility(or Generator) J U LL Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) Q Z 2 hd 19.Hazardous Waste Report Management MetoCodes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 11 1 2. 0 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year Signat I Printed/Typed Name ' EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FA Y TO EPA's e-MANIFEST SYSTEM A700-JJ 12v3 CAL20060112 540025214 041808247 M PD071120 SD071120