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O Qo (D <br /> D <br /> v0 poo <br /> TI O O O O <br /> o 00 C3) <br /> a Co 0 <br /> wNNO cn <br /> M _ � � � v N) <br /> r O W N C n <br /> � –n 1l 1l Ln <br /> ® C. <br /> RppUSdes'g I Geet se on nerato,D Nomber2-Pikh)typewriter.) ER N� m m M O <br /> 00 <br /> st CAR00@259515 z.Page 1 p1 3�Eme en Res �I/q 11811 Form to C71 OD OD 3 � <br /> `aNfE 1 r9 nY lance Phone 4.ManBeet Tni i in N roved OMB fVo.20600039 00 <br /> btaa�ng addre� $009246804 <br /> cus (sIs) #17412 GenemlorsSit,Address Itdtllerewthanmalmg,d011434310 FLE m (D <br /> rj041 16858 Golden Valle CVS (SIS)#17412 O 0 O (n D <br /> Y Pkwy, .� <br /> Lathrop, CA Ys Suite B 16858 Golden Valley Pkwy, Suite G <br /> 9533@ m <br /> '•�pony Name LathrO <br /> P, CA 95330 C <br /> Stericycle Specialty Waste Solutions Inc US EPA ID Ill <br /> 1rpmpany Name MNS000110924 -01 4:�- W O <br /> bi �nc� /7-5Ni T US.EPA ID Number O O (O - CD <br /> 1 0 <br /> MO p �'9✓�, <br /> Faau1'Name and Slte Address e S en Ury O O (O Z3 <br /> p C7 <br /> s ` �� � � � <br /> 2095 Newlands Dr. East US EPA ID IN1 `� O n <br /> Fernley, NV 89408 Z3 y <br /> Alone 7755752^760 N <br /> NVD980895338 CDD <br /> ,Cn U.S.DOT Desrnptlon(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> ad Packing Group(A any)) 11.Total 12.Unit <br /> No. Type OuanNy M/Vol 17 Waste Ciiys <br /> UN2810, Waste Toxic, liquids, organic, n'o'" <br /> 1 CF <br /> 00021 P 311) 0007 0024 <br /> (M–Cresol, Thimerosal)} 6,1a PG II, ERG#153 <br /> (D <br /> ,,UN2811, Waste Toxic solids, organic, n.o.S. 1 CF 00203 P 31 D007 DOI@ <br /> (Chronium, Seleniur), 6.1, PG II, ERG#154 O <br /> r� <br /> I O <br /> 'UN3249, Waste Residue Last Contained, 1 CF 000Q1 P 311 R001 O <br /> Medicine, solid, toxic, n.o.s. (Warfarin), — ~' <br /> 6.1, PG II ERG#151 (p <br /> Jpedal Handling lnstruchons and Additional Information i.I00687(RX Toxic Liquids) 2.100196(RX Toxic Solids ) 3. <br /> 101079(Residue weioht does not exceed 0.0436 lbs) CNT:19 <br /> c, <br /> _ _ C:) <br /> r5. GENERATOR'SIOFFEROR'SCERTIFICATION:(hereby declare that me contents of this cons,nment are full and acaralel desaibed above b me m r sh .0=0) <br /> marked and labetediplacarded,and are m all,e - 9 y y Y Pat ip exp name,and are dans the <br /> spells m proper condition l s transport according m knMedg int of tion s aril national governmental regulations.Il expon shroment and jam me Primary w � <br /> Exporter,I certify that me wrMnls of m'�s consignment conform tome terms d the attached EPA Acknowledgment of Consent, 01 W <br /> I cendY that the waste minimvation statement Identfied in 40 CFR 262.27(a)(if I am a large quantity generabr)or f III I am a small quandry gene is true. (O 00 GJ <br /> Generatoes s Merl Name �� igna ure 'n -4 N W <br /> ea <br /> 16 In@mational Shipments 08 15 201 N M C> <br /> G— ❑Import m U.S. ❑Export from U.S. POrt 01 en xil.L <br /> Z Trans iter nature to ex on <br /> K 17.Transporter AcknwAedgmerndReceiplofMatemis Dalelea m U.S� r r r <br /> Transporter 1 PnntedRyped Name m m m <br /> NIsidro Martinez gnature on ay ea <br /> z Transporter 2 Printed Name - 08 15 201 M 00 <br /> /J Sigreture _ <br /> fw �C /�j�q y ear <br /> 18.Drscrepancy - V 7 /O O (�)1 <br /> 1 v <br /> 18a.Disaepanq Indication Space M 00 00 <br /> ❑Ouanliry ❑rvpe �..i�..i <br /> Residue ❑Partial Rejection ❑Full Ra ^^^ <br /> lection <br /> 186.Alternate Faasty(azi <br /> Generator) Manifest Reference Number ^� <br /> Q U,S.EPA ID Number �'/ <br /> �- Fallot 5Phone <br /> w 16C.Signature ofAhemate Fadliry(a Generaor) CD O CD <br /> a O O O <br /> Alonth Day Year n - 0 <br /> Haxamws Was-re Repot MenagemaM Metlwd Codes li.e..codes tar hazardous waste beat-m disposal,end <br /> 1. <br /> 2 mcydm9 systems) 0 <br /> ` 1 � o <br /> 1 1q <br /> 2 I Des'gnak4 FaUay Dn+tera(>frerotor:Cerafaar Q <br /> Printro/Typed Name 1On of receipt of hazardous materiely covered by the manifest oxcepl»s noted in Item 18a <br /> S lure Q <br /> EPA Form 8100-22(Rev.3-05)previous editions lete. <br /> are obsoDaY Yenr <br /> CD lD12 1�- <br /> DESIGNATEDFACILITY TO DESTINATION STATE(IF REQUIRED) CD <br /> co <br /> 0 W <br /> O) <br /> = — CD <br /> 4 <br /> —4 <br />