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i",t <br /> On <br /> "M <br /> 4 <br /> -7v -ok7�,' <br /> �Tbrm <br /> '()IVIB W2 <br /> I EM NU be' <br /> UNIFORM HA2A]Rbous J1,Gena4tor.ID,Nurnb6r' t 2:Page 1 o erg6�cy:Rqsp6*P 6*� �Mlanlfest Trackin m r, <br /> WASTE IWANIF15ST, ?) <br /> 1 0 §001 `DA <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> City god U. of Sari Ftanclace SWeL FILIElt <br /> 1391 barkat St., 5111(i 211 lud <br /> Generatoes Phone:" - San FrAmisco,;A SOP 1415182-3571 1 somal CU U58i <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC HNS000110924 <br /> 7.Transporter 2-Company N e U.SAArg <br /> iv <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 2J.S1 CENTURY RVINIMM WAR0110 OF.SUM. LLC <br /> 2e95 ROVIAMS kr6t East <br /> FaciliVs Phone: IFEIRLEY, SU 114111 (71.5) 515-2768 N09HU095330 <br /> ga. 9b.U.6-.'bOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers, 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt;Nol. 13.Waste Codes <br /> KIP w0f2 U.4.: <br /> now Lfulitl I <br /> *10"Ic OM"Son" "SMTE),I K 12). <br /> Wit <br /> A0 <br /> 4" <br /> -A 4" <br /> C- <br /> L J <br /> Q0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 111 RCCCSFFLii -#2 - MOW F <br /> 15. GLENERATOR!SIOFFEROR'S CERTIFICATION: Ihereb declare that the contents of this consignment are fully and accurately described aboV.e,by the proper shipping name,and <br /> ... —Y arezlassified;packaged, <br /> marked and labelecliplacarded,,and are in all:respects in proper condition for transpo.rt'according.to applicable internaflorfalancr,nabonalgovemdt6ntaI regulations:If shipment and.I am the Primaq <br /> Exporter,I certify that the cont Is ofthis..cqs' Jent6ofiform.to the terms of the attached EPAAckh6wledgment of Co a t <br /> 0 <br /> conte <br /> tatement identified in 40 0 generator)o (b) ira 11 quantity gen <br /> pnm <br /> I certify that ft Waste minimize FR 262.27(a)(if I'm a large gene r <br /> Gqneratoes/Offeroes Signa Month Da, Year <br /> Y, I <br /> y it <br /> 16.International SJ <br /> Exportftom,6S Port- <br /> I ipme,"t <br /> n-ylexif. <br /> S'6 <br /> ragsporle AignatUrdi(forqxportsoqly <br /> Date davin <br /> owledgfnohtO(R�Ocdipt-6 M <br /> f 6 <br /> I-- Transpbrier-T PrIntqd/,Ty0ed Name '�'Day <br /> ,Month'— Year - <br /> X10 <br /> Z Transporter 2 Printetyped Name J .*nth. 'Day• ar <br /> 18.Discrepancy V. <br /> 18a.Discrepancy Indication Space <br /> 0.quantity El Type ❑Residue 'Partial Rejection ❑F" 10 <br /> ull Reject n, <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> —J has the appropriate permits(s) <br /> LL. Facility's Phone: for, and will accept the waste <br /> a I Month <br /> ,1-!Is Day. Year <br /> W 18c.Signature of Alternate Facility(or Generator) generator is shipping. <br /> C9 <br /> a "de� cod s ;44rd6 s1d I <br /> f <br /> a r <br /> epc�t M�p6demorijt M Co <br /> us <br /> 4: <br /> ILI* <br /> 1�I-Z <br /> .Approved <br /> U—NR <br /> "0 M <br /> WASTE I <br /> 5 Generator, <br /> rtlficahohof receipt,of,hazardous,materials 00 die Ale, <br /> red'Oy th. 7 <br /> Printed/Typ <br /> ed N Sig ature Mon'th Y <br /> EPAFortn:8700-22(Rev. 1/0 <br /> 12-11F Previous editions are obsolete-,-, v <br /> DESIGNATED FACILITYTO GENERAT5 <br />