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Please printori pe:..- .'" Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pae 1 of 3.Emer enc Res onse Phone .Manifest Trackin Number <br /> UNIFORM HAZARDOUS 9 g Y p ,`ej �`�Q(� /�T <br /> WASTE MANIFEST CAR0110295932 C877� 577~26fi ,o o" � i V V V DJ'�I <br /> 5.Generator's Name and Mailing Address Generator's.Site Address(if different than mailing address) <br /> ,CITY PI CCE91n OF SFFUC TNCT FAEILITY CITY 0 CQII}(TY OF ;FPUC TINT FACI(ITY - <br /> 1398 MOLT S3'ILL STF 2.11 9919 VEST VER1suls. Im <br /> Generator's Phone;. - SV FRUIV 0 4I82' 04151262-3177 Awy G Wit <br /> 6.Transporter 1 Company,Name U.S.EPA ID Number <br /> STERICYCLE SPE:CIRLTY WASTE SOLUTIONS INC t1N50CfL11Ifl��4 �' <br /> 7.Transporler2Co ,anAName.,. t i.. i- ,., «U.S.EPA-IDNumber;. <br /> _ . <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21ST CV MY EYVI `E1sTHL &0M' NX IF Wpm. LLC ��t <br /> 21195 N",lads ki" East <br /> Facility'sPhone: Ffi fao9V "490 (7751 535-2168 NVD900895338 <br /> ga, 9b.U.S.DOT 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 ivol. .13.Waste.Codes <br /> W <br /> O D P <br /> W <br /> 00 f 1 <br /> Z 2. 1f►:r`+! ii;fi;t E L 40 r 1 riip .(�. . 1 1NI L <br /> C7 X DF P <br /> 3. .10-7F I >U rVasil, LET r <br /> X DI= r. o P j <br /> 4. <br /> n <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by ttre 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 thinittached EPA Acknowledgment of Consent: <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if lam a.large quantity generator)or(b)(ifl'am a sm antity generator)is true. <br /> Generatoesl Pri a yped Name Signature Month Day. Y ar <br /> ° ° l012, <br /> 16.International Shipments g <br /> &_ ElImport to U.S. ❑Export from U.S. Port of entry/exit: n <br /> ? Transporter signature(for exports only): Date leaving U.S.: 4 <br /> W 17.Transporter Acknowledgment of Receipt'of MaterialsLU <br /> H <br /> TransFAer 1 Printed/Typed Name Signature Month Day Year <br /> Tra porter 2 rinted/Tgped Name Signature. Month Day Year p <br /> r:olti $' 1 <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑'Quanti ❑Type ty yp El Residue ❑partPal Rejection EJ Full Rejection <br /> a <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _ iae- y�propriate-perm its(0 <br /> LL Facility.'s Phone: ill aCCe t the waste <br /> d <br /> w 186.Signature-of Alternate Facility(or Generator) Month Day -year, <br /> a this gs�r►gfa�tor is shipping. <br /> Z <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. 2. 3: k i 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed. ped � � SignaturF M th pay y <br /> EPA Form 8700-22(Mev.12-17) Previcits editions are obsolete. DESIGNATED FACILITY 0 GENERATOR <br />