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H. 911, 1111Please print or type.(Form designed for use on elite(12•pilch)typewriter.) _RTw.ter- � _ Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Pa g 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAR117100E3 i 71 12 80092°46604 010076875 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) CVS 4,985+2: CVS#CA9830 2099516544 6632, Pacific Avenue JGJL ''acif is ilVelll{e Generatofs Phone: Stockton; CC, 952 !2+7 St Dcktori. CA r�5207 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solations i:1c MN k)0W1109c4 7.Transporter 2 Company Name / U.S.EPA ID Number py p 8.Designated Facility Name and Site Address St e r i c y c 1 e, 1 n C U.S.EPA ID Number 2670 Executive Drive Indianapolis, lid 'f6�4i. Facility's Phone: 17524561! I h�R��2+ 1 tr 19! oa 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(it any)) No. Type Quantity i WtNol. UiA3248, s-)aCte Medicine, liquid, flammable, i. �:vI00 P 3;1 IJ0711 � O toxic, FI. D� S. (Aleoho1) , 6, 1, PG 11, ERG# I--- 131 Z 2. rl.t 3. ) 4 14.Special Handling Instructions and Additional Information 1. 1 IQ;: 6 (R7. -St at e R e q u i at ed.' 15 GENERATOR'SIOFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and nalionaI gov omental regulations.If export shipment and I am the Pnmary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I aRi a s II qu li generator)is true. 701femi's Printed/Typed Name Signature Month Day ear �— , tic'; 1 28 [2-017 nternational Shipments � 77 F- ❑Impo t to U.S. [J Export from U.S. Port of entrylexiC -- 1 rnspDrter trnsporter signature for exports only): Dale leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Prinled/Typed Name Signature : Month Day Year CO Kristopi-ier Alfnanza I I C'19 ,'8 I-v_fi r Z Transporter 2 Printed/Typed Name _ pp n- L Signatur Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ cxanlily ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 1 Bb.Allemate Facility(or Generator) U.S.EPA ID Number U Q LL Facility's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year F- Z Z 2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJ 1 2. 3. 4. 20.Des ted Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest e5006 noted in Item 1 P' ed/T d me Signal � � Month Day Year EPA Form 87 -22(Rev.3.05) Previous editions ar bso ete. MIGNATED FACILITY TO DESTINATION S ATE(IF REQUIRED)