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RT ,ie N`Form roved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) E MP <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trakl Number <br /> WASTE MANIFEST CA 800023171 2 18009246804 0 0 8 l 7 5 4 8 7 F L E <br /> 5.Generators Name and Mailing Address Generator's Site Address(it dMerent than mading address) <br /> CVS#09830 <br /> 2099516544 6632 Pacific Avenue <br /> Generator's Phone: Stockton, CA 95207 <br /> 6. ransporter i Company Name U.S.EPA ID Number <br /> CD <br /> Stericycle Specialty Waste Solutions Inc IMNS000110924 <br /> T.11anspooet2 Company Name U.S.EPAtD Number <br /> Z <br /> 84 pesignated Facility Name and Site Address Genera! n v 1 r o n m e n L a VICE. l, U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742- <br /> Fa(ilit)(s <br /> 5742Facility's Phone:9163510 9 8 13 CAD980884183 <br /> ga 9b.U.S.DOT Descrip0on(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packirg Group(if any)) No. Type Ouant y WWo1. <br /> X UN2811, Waste Toxic solids, . organic, n. o. s. 1 DF 00069 P 311 D007 010 <br /> o (Chromium, Selenium), 6. 1, FIG II, ERG#154 <br /> W X ;JN1993, Waste Flammable liquids, n. o, s. 1 DF 00081 P 2 <br /> 214 D001 00 <br /> 0 (Alcohols, Acetone), 3, PG II, ERG#128 <br /> Ion RCRA hazardous waste, liquid 1 DF 00093 P 331 <br /> Consumer Electronics for Recycling 1 DF 00053 P 181 <br /> 14.SpecialHand!inglnstruCGonsandAdditionallnfomration 1, 103446(CA Solid Pharmaceuticals) 2. 100198(Flammable Liquids) <br /> 3. 102979(State Regulated Liquids) 4. 100312(Consumer Electronics ? <br /> 15. GENE RATOR'SIOFF EROR'S CERTIFICATION: I hereby declare that the contents of Ws consignment are fully and accurately described above by the proper shipping name,and arc dassified,packaged, <br /> marked and labelediplacarded,and are in ail respects in proper condition for transport according to applicable international and national governmental regulations.II export shipment and I am the Primary <br /> Exporter,I certify that the contents of this corsi nmenl conform to the terms of the attached EPAA6=0edgment of Consent. <br /> certiiy that the waste minimization statement identified in 40 CFR 26227(a)(it I am a large quantity generator)or(b)(d I am a small quantity,generator)is true. <br /> Ger+araloes7 roes Pri Name gna re on ay ear <br /> f—G[n l.rltLJP 07 19 <br /> ibl.In emabonai Shipments <br /> r- ❑Import to U.S. El Expo t from .S. Part of enbylexil: <br /> Transporter s' n.Murei tior ex Dale leavmg U.S,: <br /> 17.Transporter Admadedgrnent of Receipt of Materials <br /> � Transporter 1 Printed/Typed Name +gn —, Month y � <br /> a Phil Marciel 1c 07 015 <br /> rn <br /> M Transporter 2 Printed/Typed Name Signa re More Uay Year <br /> Q <br /> OC <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy In&cat on Space 0 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> lab.Altemate FaaTty,(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL Fad1i s Phone: <br /> LU 182 S gnaum of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) /J <br /> 0 1 2 3 1 4 �f <br /> 20.Designated Facility Operator Certification of receipt of hazy s matedats covered by the manifest except as n Item 18a <br /> Pn led7Typed Name SignatureMonth Day Year <br /> (� ( 2 ( l (S <br /> EPA Form 8700-22(Rev.9.05) revious editions are obsolete. DESIGNAT F ILITY TO DESTINATION STATE(IF REQUIRED) <br />