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'4 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pag?of3.. mergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAR00023171c 009^246804 010867665 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> CVS #9830 CVS#09830 <br /> 2099516544 6632 Pacific Avenue 6636 Pacific Avenue <br /> Generator's Phone: Stockton, CA 95207 Stockton CA 95207 <br /> 6. ransporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address St er i cyc 1 e, Inc. U.S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> Facility's Phone: 3175245617 I NR000110197 <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 Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> X 1UN3248, Waste Medicine, liquid, flammable, 1 CFP <br /> 3111 D00 'I <br /> 0 toxic, n. o. s. (Alcohol), 3 6. 1, PG II, ERG#-11 <br /> 131 <br /> Z 2 <br /> 3. I i <br /> 4. <br /> i <br /> ) <br /> + a <br /> 14.Special Handling Instructions and Additional Information <br /> 1, 102966(RX State Regulated) <br /> 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, <br /> marked and labefedlplacarded,and are in all respects in proper condition for transport according to applicable international 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 EPA Acknowledgment of Consent. <br /> 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 am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> oM <br /> 16.International Shipments <br /> � ❑Import to U.S. El Export from U.S. Port of entrylexiC <br /> Transporter signature for exports only): Dale leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnnted(Typed Name Signature on ay Year <br /> a <br /> zTr <br /> anspo er 2 rine ype ame— Signature o <br /> �;-A amu I F �71 Il <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Altemate Facility(of Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Phone. <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19 Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1' 2 3. 4. <br /> 1 <br /> 20.De le acility Owner or Operator: ertification of receipt of hazardous materials covered by the a xcept as noted in Item 18 qxN �nAjj� <br /> S na e MDay <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 871210—'r'P i r u? r.01P009121641 .r,4gl!M t5Ac�7 nA I is 40g9 M Pn01F.t=-1 A CM-Ar i Ol a <br />