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<br />Please print 01 type.
<br />EPA Form 0700.22 (Rev. 3-05) Previous editions are obsolete. 0
<br />(Form designed for use on elite (12•pilch) lypewdler. corm proven. umn nu. t�av woo
<br />UNIFORM HAZARDOUS 1. Gonorelor ID Number
<br />A L 0 0 0 4 1 6 D
<br />2. Page 1 of
<br />3. Emorgerwy Response Phone
<br />any 25
<br />14. Manifest Ttacidng Number
<br />0 i� � 9 0* J 4 9 FLE
<br />WASTE MANIFEST D 7 8
<br />2
<br />5446
<br />NNE
<br />6, Gonoraio a Name and MailingAddross At* Joson Mor dy Generabfa SdeAddress ( dPereM ltan rna -rq ahJressl
<br />Suitor Mould Medical FDUdoNon•Stoc.11ton Medical Plaza
<br />21608 W, Harr Ln
<br />Stockton CA 93209
<br />Generator's Phone: 6
<br />Transporter I Company ampUS EPA 10 Number
<br />Neal{Ihv�lca �arv(ctb s CAL 4 A 0 3 7 0 1 l A MON
<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />G. Designated Facility Name and Site Address U.S. EPA ID Nurrber
<br />Veolle ES'Thohnlcal'So0
<br />1125144,14y Strat 1gVP4%ar^1 1` 1111 ,1 :T
<br />r
<br />RIshlf nti CR" iH(11 '41�u' to c -N ' i 1—in L 1
<br />,
<br />FadliryJsPhone: e; ii`
<br />ga
<br />9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number,
<br />lotcon
<br />11. Tobi
<br />12, Und
<br />13 Waste Cedes
<br />No
<br />Type
<br />HM
<br />and Packing Group (if any))
<br />Quantity
<br />VA AV,
<br />Ir
<br />x
<br />1UNi85t, MSTEMedleine, liquid, to�:lo, n,o,s teadufnSuvllts)
<br />s,1, PGII
<br />39 o
<br />51
<br />DF
<br />P
<br />W
<br />X
<br />2UN2811, WkgrE Tcomle soilds, or0enle, n!o.s. (M -Cresol)
<br />8,1,
<br />��
<br />31 i
<br />11
<br />24
<br />PGII
<br />C{
<br />DF
<br />3 U 19930 vkASTE FIWWMblo liquids, n a,a, (Etrryl blrohol, Isopropanol)I
<br />1
<br />? 12
<br />?n t
<br />X
<br />3, Pall
<br />I f O
<br />P
<br />X
<br />4UN 11131, VAASM Medkine, liquid, toxic, n.o.a (Chloranibucll,
<br />Mrrlphalan)
<br />1
<br />LP
<br />010
<br />J035
<br />1;35'
<br />70
<br />6.11 P411
<br />DF
<br />105q
<br />J1150
<br />14.SpedalHandling Instructions and Additional Information 1)877429ERGIIII51 2)877430ERGOJ54 3)877432EP01111128 4)+3117531 ERGS15I (A"sr• 311
<br />;kx 55 JLX 521
<br />15. GENERATORWOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classfied, 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 or this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I em a largo quantity generator) or (b) ' I sm a small quantitygenerates) is true,
<br />VIIeralo;ACICnrsionerors Print Stied am0. n l i� r goes `,, ` a
<br />—t
<br />F
<br />11110
<br />16. International Shipments
<br />❑ Import to U.S. El Export from U.S. Pad olentrylexil:
<br />Z
<br />Transporter sinature for exports onl: Dole leaving U.S.:
<br />17. Transporter AdmWedgmenl of Receipt of Materials
<br />Trans iter P nfeNr d Name r Signature on ay Year
<br />o
<br />}, r
<br />f '' !/ t
<br />'
<br />QTransporter
<br />2 Pdnied/Typed Name Signature Ih Day Year
<br />a
<br />18. Discrepancy
<br />10a, Discrepancy Indication Space ❑ ouantity ❑ Type ❑ Residua ❑ Partial Rejection ❑ Full Re*Wn
<br />Manifest Reference Number:
<br />i 8b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />U
<br />LL
<br />Fadli s Phone:
<br />Q
<br />18c, Signature of Ahemale Fauliry (or Generator) Month Day Year
<br />z
<br />Matta
<br />e eport Management Method Codes (I.e„ codes`forihazardous waste treatment, disposal, and recycling systems)
<br />IS, Hazardous WasEDes�naled
<br />�23.
<br />{ l
<br />4.mer
<br />or Operator. Certification of recelpl of hazardous materials covered by the manifest except as noted In Item 188
<br />Signature hlonlh ay Year
<br />iiE!";'i: COPY
<br />
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