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M <br /> r, uuWWf <br /> Please print or type-(Form designed for use on elite(12-pitch)typewrite ) ER11I x'101_ Form Approved OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 12,Page 1 of 3,Emergency Response Phone 4.Manliest Tracking Number <br /> WASTE MANIFEST CAR000231712 8009246804 009157113 FLE <br /> -T-Generator",ame and MaTing Address Generator's Site Address(it differed than mailing address) <br /> CVS #9830 Cu6#09830 <br /> 2099516544 6632 Pacific Avenue 6632 Pacific Avenue <br /> GeneratOPMne: Stockton, CA 95207 Stockton, CA 95207 <br /> 6.Transporter 1 Company r1larM U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name US EPA ID Number <br /> 21st Centur Environmental Of California CAR000210617 <br /> 8.Designated Faality Name and Sive Address St e r i cyc i e, Inc. U.S EPA ID Number <br /> 2670 Executive Drive <br /> Facilitys Phone: Indianapolis, IN 46241 <br /> i <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Parking Group(if any)) No. Type Quantity wt.lvol. <br /> Non RCRA hazardous waste, solid 1 CF 00002 P 31 <br /> v <br /> Z 2. <br /> w <br /> c9 <br /> 3. <br /> 7-- <br /> 14.Special Handling Instructions and Additional Information <br /> 1. 102967(State Regulated Solids) <br /> i <br /> I <br /> I <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I herebv decare that the contents of this consgnment are f0y and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and tabeledlplararded,and are in all respects in proper condition for transport according to applicable international and national governmental r tans.II export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. s <br /> I cert fy that the waste minmizatloo stalemert iden Vied in 40 CYR 262 27 a ;if I am a lar a uanti; gen ator or it I am a sd a rator is <br /> (} 9 4 Y9 } O( <br /> s101fefors ypel acme r 1MonLh Year <br /> IGt�fG-i'�L� 1 0 201 <br /> t . I,emabonal Shipments / <br /> � ❑Import to U.S. 0 Export from U.S. Port of entrylexit <br /> z <br /> Transporter signature for exports only): <br /> Date leaving U.S.: <br /> 17.Transporter AcknaMedgment of Receipt of Materials <br /> Uj <br /> Transporter 1 Pnnted/Typed Name Signature MonN ay ear <br /> JohnnyHar <br /> per <br /> 1 01 2016 <br /> Z Tra porter 2 Print Name Signature ontn ay ear <br /> i Q � <br /> cr <br /> r <br /> 18.Discrepancy rr II <br /> 18a.Discrepancy Irdiration Space Quantity Type ❑Residue l_�Partial Rejection u Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Q <br /> r+ Faallt s Phone: <br /> LU 18c.Signature o1 Alternate Faafity(w ner <br /> GealoT) Month .Day Year <br /> Z2 <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU , 2 3. 4. <br /> 0 <br /> 20.Designated Facility O,vner ar Operator:Certification of receipt of hazardous materials covered by the manifest except as not Item 18a <br /> Print Name Signature Month Day Year <br /> CS4— <br /> EPA Form 700-22 I ev, -05) Previous editions are obsolete. DESIGNATED FACILI r 0 DESTINATION STATE(IF REQUIRED) <br /> A70tf7t_Pt 1 err% 1"Q1 P00g17tfr.41 CZAMIIVAJ�Inc�.7 nAM7a1?fhl M on 1 W2 i G cns Ira,1 c <br />