COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please'print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST CAR000231712 2 8009246804 010788942 F L E 5.Generators Name and Mailing Address Generator's Site Address(If different than mailing address) CVS #9830 CVS#09830 2099516544 6632 Pacific Avenue 6632 Pacific Avenue Generators Phone Stockton, CA 95207 Stockton, CA 95207 6 Transporter 1 Company ame U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility ame and Site Ad ress ent ury EIVIN, LLU 4 U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facllitys Phone: 7755752760 N V D980895338 9a. 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 0.Containers 11.Total 12.Unit HM and Packing Group(if any)) No Type Quantity Wt.Nol, 3.Waste Codes 1 UN1950, Waste Aerosols 2. 1, E #1" 1 CF 00013 P 214 D001 O --- Z X2 UN3249, Waste Residue Last Contained, 1 CF 00001 P 31 P00 UJ Medicine, solid, toxic, n. o. s. (Warfarin), — I 6. 1, PG II, ERG i #151 1� X3 UN2811, Waste Toxic solids, organic, n. o. s. 1 CF 00005 P 31 D00 . D01 (Chromium, Selenium) , 6. 1, PG II, ERG#154 -- X4 X4 UN2811, Waste Toxic solids, organic, n. o. s. 1 DF 00074 P 31i D007 D1211112 (Chromium, Selenium), 6. 1, PG II, ERG#154 ------ ---- ------ 14.Special Handling Instructions and Additional Information 1. 100201 (Aerosols, Flammable) 2. 101079(Residue weight does not exceed 0.0436 lbs) CNT:151 3. 100196(RX Toxic Solids ) 4. 103446(CA Solid Pharmaceuticals) /j—l C—W/fir` g*tW%A-X 11t/ 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the 96nients of this consignment are fully and accurately described above by the proper shipping name,and are classed,packaged, 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 Exporter.I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent I certi that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)Iii I am a#all enerator)is true. Gen or'sl ror's PnntedrTypV NameU�� ign � on ay Year K Iq 21 2017 J 16.International hipments H E]Import to U.S. ❑Export from U S. Port of e le it Transporter signature for exports only): Date leavinc .S w 17 Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name ignature Month Day Tear XO Johnny Harper I I 14 24 2017 z Transporter 2 PrintedlTyped Name / Signatur Month Day Year 18.Discrepancy 18a.Discrepancy Indication SpaceQuantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: gZ 18h Alternate Facility(or Generator) U.S.EPA ID Namber J U Q �+ Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) W 1 2 3. 4. D k� q 11 1 R I � I I _ _ P /qL 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name 1 ) Signature Month Day Year x/ / EPA Form 870 2 (Re . -05) Previous editions are obsolete. DESIGNAT ACILITY TO DESTINATION STATE(IF REQUIRED) 8700-2212v3 CAL20090641 S40005857 041004222 M PD122217 SDI22217