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[pill FormA roved.OMB No.2050-0039 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) PP UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response P one 4.Manifest Tracking Number WASTE MANIFEST 012121 F L E 5.Generator's Name and Mailing Address Generato s Site ress(d different than mailing address) CVS #9830 CVS#09830 2099516544 6632 Pacific Avenue 6632 Pacific Avenue Generators Phone: Stockton. CA 95207 rit nrLit Transporter 1 Company Name U.S. PAID Number Steric cle Specialty Waste Solutions Inc MNSM0110924 7.Transporter 2 Company Name U.S.EPA ID Number NC. 8.Designated Facility Name and Site Address ?JSt Century EMIN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone:7755752760 NVD980895338 ga 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(if any)) No. Type Quantity Wt.Nol. Waste Toxic solids, organic, n. o. s. 1 CF 00006 P 311 PI P075 o (Warfarin, Nicotine), 6. 1, PG II, ERG#154 zA JJN1996, waste Flammable liquids, n.o. s. 1 BA 00019 P 214 D001 U$02 (Alcohols, Acetone), 3, PG II, ERG#128 X jUN1950, Waste Aerosols 2. 1, ER6N126 1 BA 00016 P 214 D001 X JUN2811, Waste Toxic solids, organic, n. o. s. 1 CF 00003 P 311 D007 DO10 (Chromium, Selenium), 6. 1, PG II, ERG#154 14.Special Handling Instructions and Additional Information 1. 100205(Acut e T o x is So 1 i d s) 2.PKG—DF:100198(F 1 am nab 1 e Liquids) 3.PK6—DF:100201(Aerosols, Flammable) 4. 100196(RX Toxic Solids ) 15. GENERATOR'SlOFFEROR'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 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 EPAAcknowledgment 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 am a small quantity generator)is true. enerator eros nn yped Name Signature on ay ear Q v�I or C ra-rC"I A- 09 as I 201 16.International Shipments F ❑Impart to U.S. Export from U.S. Port of entrylexit: Z Transporter signature for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name i9nature Month Day Year o Isidro Martinez 09 08 201 M x Tran 2 Punted hyped Name gnatu on ay ear F 9, 2A 19 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑TypeE❑ �i{� I'rbalcig Relen 6 Full Rejection Manifest Reference Number. 181b.Attemate Facility(or Generator) U.S.EPA ID Number J OCT 1 1 ?_018 v a U Facil.'s Phone: Month Day Year w 18x.Signature of A ternate Facility(or Generator) g_ V I R O IV►1/1 E N l A r' I EA LTF Q Z S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ' D t' 1 2 � J I 3 ) ' 4 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 Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) 8700-2212v3 CAL20090641 S40005857 041196797 M PD090818 SDO90818