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<br /> Please print or typo.(Form designed for use on elite(12 pitch)typewriter.) p ��111 1� AUI i IIL� 1111�1Yf� E �I�l�ul�lllllllf Form Approved.OMB No.2050-OD39
<br /> UNIFOR•d HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Picone 4.Manifest Tracking Number
<br /> WASTE MANIFEST �� _ 008570609 FLE
<br /> 5.Generator's Name and Mailmg ddress Generator s SiteAddress(if different Than mailing address)
<br /> CVS#09830
<br /> 2099516544 6632, Pacific Avenue
<br /> Gimerator's Phone: o
<br /> 6. ransporler 1 Company Nome
<br /> U.S.EPAIDNumber
<br /> V
<br /> St r i r } U.S.FPA ID Number
<br /> \ 7.T� p 2CgmpanyName
<br /> 8.Designated Facility o and Site Address U.S.EPAID Number
<br /> General Environmental Mgt, LLC
<br /> ii$55.White Rock Road-.
<br /> Rancho Cordova, CA 95742
<br /> Fadllly's Phone
<br /> ga 91b.U.S.DOT Descripton(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 72.Un 13.Wasto Codes
<br /> HM and Packing Group(if any)) No. Type Quantity
<br /> o X bN2811, Waste Toxic solids, organic, n. Q.s. 1 CF 00006 P 311 D007 010
<br /> (Chromium, Selenium), 6.-1, PG. 11,. ERG#154,
<br /> 2 X 61`13077, Waste Environmentally hazardous 1 CF 00002 P 181 D009
<br /> substances, solid,. n.o. s. .•((dercury), . 9, .PG.
<br /> TTT. FIR #171
<br /> X N2811, Waste Toxic solids, organic, n. o. s., i . CF• 00006 P 311 D007 010
<br /> (Chromium, Selenium) , 6. 1, PG I?, ERG#154
<br /> X N3249� Waste Residue Last Contained,. i CF 00001, . P 311, JP001
<br /> Medicine, solid, toxic, n. o, s. (Warfarin),
<br /> 14.SpedalH ndlinglnstruc4o sandAddbonatlnformaUon 1, 100196(RX -Toxic Solids ) 2. 102964(Broken Fluorescent Bulbs)
<br /> W. 103446(CA Solid Pharmaceuticals) 4. 101079(Residue weight does not exceed 0+.0436 lbs)
<br /> C'IVT:Ee
<br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: thereby 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 labelecilplacarded,and are In all respects In proper condition for transport according to applicable international and national governmental regulations 3 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 Ural the waste minhnizabon slatement idenlifled in 40 CFR 262.27(a)t=�koif��
<br /> go quantity generator)or(b) d I am a small quantitygenerator)is tnre
<br /> Gonorator 0l erors Pnnlednypcd Name ( on ay Year
<br /> .-J 16.international Shipments ❑> port from of en exrhimport to U.S. ti)Trans orters nature for expertsonl leave 5
<br /> 17.TransportorAcknowledgmem of Receipt of Materials
<br /> Transporterl PnnledlTypedNamo gnature onh ay ear
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<br /> z Tra Name 2 Fnnl tlypcd Nae S+gnalura Man> ay Year
<br /> flu- -�- - �,- t� A"
<br /> 18 Discropan
<br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Parbal Rejection ❑Full Rejection
<br /> Manifest Reference Number.
<br /> 18b.Allemoto Facility(or Generator) U.S.EPAfD Number
<br /> .1 -
<br /> U
<br /> Q
<br /> u
<br /> Facility's Phone:
<br /> Jj n loc.Signature olAflemateFacility(or Generator) Month Day Year
<br /> Q
<br /> a
<br /> F20.Des�nalc'd
<br /> s Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems}
<br /> 2, 3 `1 4
<br /> IM
<br /> Facibry Owner or Operator.Cerlification of receipt of hazardous malerials covered by themanifest except as noted in Item i8a
<br /> Cod Nome f' V V Wv F, Srgnaturo Month Day Year
<br /> M ti R 116 11 �
<br /> cr,) EPA Form 8700.22(Rev.3-05) Previo s editions area so!ete. ESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)
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