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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 f 3.Erne en Res Form Approved.OMB No.2050-0I <br /> WASTE MANIFEST rig cY pone Phone 4.Manifest Tracking Number <br /> 5.Generators Name and Mailing Address - 011387023 F L E <br /> Generators Site Address(if different than mailing address) <br /> CVS #9830 CVS#09830 <br /> 2099516544 6632 Pacific Avenue 6632 Pacific Avenue <br /> Generators Phone: CA 95207 <br /> 6. ransporter 1 ompany Name Stockton CA 952207 <br /> U.S.EPA ID Number <br /> Steric cle S ecialty Waste Solutions Inc <br /> 7.Transporter 2 Company Name MNS000I 10924 <br /> U.S.EPA ID Number <br /> X 3 <br /> 8.Designated Facility Name and Site Address EQ IS 2-113 <br /> Stericycle, Inc. U.S.EPA ID Number <br /> 2670 Executive Drive <br /> Facility's Phone: ^ r,245A J <br /> Indianapolis, IN 46241 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) _ 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt Nol <br /> 13.Waste Codes <br /> o X 1' L1N3248, Waste Medicine, liquid, flammable, 1 CF 00001 R 3111 D001 <br /> toxic, n.o. s. (Alcohol>, 3 6. 1, PG II, ERG# <br /> 0 <br /> 1 3 <br /> 4. t <br /> 14.Special Handling Instructions and Additbnal Information <br /> 1. 102966(RX State Regulated) <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Cully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator orb if I am a small quantity <br /> G nerator' erues riot yped Name/� j ) {)( q ty generator)is true. <br /> �V AJ Ill g a re . <br /> on ay ear <br /> 1 � 1 International Shipments ��'YI <br /> r— ❑Import to <br /> Z Trans orter si nature for ex orfs onl Export from U.S. Port of entry/exit <br /> W 17.Transporter Acknowledgment of Receipt of Materials Date leavin U.S.: <br /> Transporter 1 Printed7fyped Name <br /> a Kristopher Aleanza gnature, <br /> U) nt Day T <br /> Transporter 2 't yped1 031 14120 <br /> F" <br /> Signa Mont Day ear <br /> 18.Discrepancy 3 2 0 <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type LJ Residue ❑Partial Rejection Dull Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number; <br /> U.S.EPA ID Number <br /> _— <br /> aL Faclli s Phone. ----_-- <br /> Wt8c.Signature ofAltemate Fadlity(w Generator) <br /> Q <br /> Z <br /> Month Day Yea <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste V <br /> LM 1.p2 eabnent,disposal,and recycling systems) <br /> 3. <br /> 4. <br /> 20.Designated Faci ity Owner or Operator:Certification of race't of hazardous materials covered by the manifest exce as <br /> Printed7fyped Na <br /> � ted in Item 188 <br /> Signature <br /> EPA Form 8700-22 13-05) Previous editions are obsolete. A1on� Day Year <br /> 1 DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRE <br /> 8700-221-12Y3 CAL20090641 <br /> S40005857 041059618 M <br /> ❑nava ,._ <br />