Laserfiche WebLink
Form r <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ER _ Approved.OMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Page'(of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAR000231712 18009246804 009156013 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d different than maling address) <br /> cus #9e3m CVS#09830 <br /> 2099516544 6632 Pacific Avenue 6632 Pacific Avenue <br /> Gen eratorsPhone: Stockton CA 95207 Stockton, CA 95207 <br /> 6.TranspoRer 1 Company Name U.S.EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc MNSOOOI 10924 <br /> 7.Transporter 2 Company Name U S.EPA ID Number .- <br /> B.Designaled Facility Name and Site Address t5tericycle, inc. U S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> Facild)rs Phone: '175245617 I NR000110197 <br /> OFgo. 9b U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, to.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(f any)) No Type Quantity M]Vd. <br /> 1. ,32 , as e e icine, liquid, flammable, 1 r 001411111 F� 51 U�JIQ <br /> toxic, n, o. s. (Alcohol), 3 6. 1, PG I1, ERG## r <br /> 131 <br /> z 2 <br /> LU <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1, 102966(R X State Regulated) <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby 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 Iabpledtplacarded,and are In all respects in proper condition for transport according to applicable intemabonal and national governmental regulations If 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 /> rtify that the waste m'nimlzahon statement Identified in 40 CFR 262.27(a)(if I am a large quantity ge tor)or(b)(d 1 a small quantity generator)is(rue. <br /> G st0llor s tinted ype me rggur� Monthay Year <br /> �-'` �t� 0 21 2017 <br /> al 7 <br /> 16"IrdmaticnalShiptnerilsE Import to U.S. Export from U S 4-t, <br /> i niry/exd <br /> El <br /> Transporters nature for exports on!y): avis U 5 <br /> Lij17.Transporter AcknovledgmentofRecelplofMatenais <br /> � Transporter 1 PnnledrTyped Nam© ignature Month ay ear <br /> C Johnny Harper 1 01 211 2017 <br /> Z Transporter Prinled od Name Signawre Month Day Year <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space puantily ❑Type ❑ResMua ❑part,")Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) US EPA ID Number <br /> M <br /> U <br /> Facili s Phone: <br /> 182.Signature ofAllemaloFacility(or Gen orator) Month Day Year <br /> z <br /> U) 19.Hazardous Waste Report Management Method Codas(I e.codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q i. 2, 3 4 <br /> 20.Des?gnai Faality Oymeror Operator.Cerl;ficalion of eipl of hazardous materials covered by the manifest except as noted n item 18a <br /> Q Pdnledfiyp d N. o Signature 1 "�) <br /> th n Year <br /> z <br /> C;) EPA Form 8700-22(Rev,3-OS Previous editions are obsolete DESIGNATED FACILITY i0 TION STATE(IF REQUIRED) <br /> 8700-22_12v3 CALC-0090641 540005857 040830843 M PD042117 SD042117 <br />