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CD Qo ( <br /> D <br /> v0 poor <br /> 71 0000 <br /> o <br /> o <br /> a - <br /> co =3 o <br /> w 000 00 <br /> fll ' N <br /> = OwN Cn <br /> � Form Approved.OMB No 2050-0,039 n TI —n <br /> ned lot use on elite(12-pitch)typewriter. ER nMea1 Tracking Nu~ r r r <br /> t Generator 10 Number 2_Page f of 3.Emergency Reapome Phare 0114 3 4 3 0 9 F LE m m m <br /> C R000259515 1 8009246804 0 C O <br /> Gener,iWl Sye Address til differ?m Man mallrtg aMreasl ti„�: (n <br /> mg dress CVS (SIS)#17412 vzt <br /> (D <br /> CVS (SIS) #17412 16858 Golden Valley PkwY, Suite M 00 W CT 3 <br /> 16858 Golden Valley Pkwy, Suite 8 N (D <br /> r <br /> La hroo. CA 95330 U. .EPA ID Numtr'r 00 00 00 fns D <br /> ny am �--��--��--� < N <br /> ric cle S ecialt Waste Solutions Inc U.SEPAIDNumber 1 /�� /^�� /�� (D <br /> pany Name ;nnnmASt $. G) UJ UJ CD <br /> I NG U.S.EPA ID Number <br /> � � w O <br /> adlity Name end SAC Address St oT'1CVC1 e, lnl.. <br /> 2670 Executive DriveO O CO D <br /> 46241 cl <br /> Indianapolis, IN INR000110197 CD w w 0 <br /> O <br /> Phone 3175245617 to.Containers D n <br /> W <br /> No. type cuam�tr an rod..U.S.DOT Desmptan hnduding Proper Snipping Name,Hazard Caumber, N. D <br /> Class ID NP 311 11001 <br /> aria Parking Group ld anrl) flasfaable, 1 CF 00001 D <br /> UN3248, Waste Medicine, liquid, <br /> toxic, n.o.s. (Alcohol), 3 6.1, PG II, ERG# <br /> C <br /> r-� <br /> CD <br /> (D <br /> D <br /> 3. — 0 <br /> O <br /> `4 Spednl Handling lnstructrons and Addihonel lnformahon 1,10?955(RX State RPpulated) <br /> Dp 9 r <br /> 15. ma(Wd and aheledlp awns d and are m all rrespectsrinoproperare that condil ofn forrttransport according to applicable intents ol lhis consignment are ny and ternational atonal accurately <br /> nd national gm,,mrnemal regullat o,If..pw shipmenta rbaz Prfed rimaryhi (^n <br /> Expoder,I certify that Me contents of this consignment conform to the terms of the attached EPA Acknowldgmem of Consent. <br /> I cediry that the waste minimizahon statement identified in 40 CFR 262 27(a)(d I am a large quantity generator)or(b)(d I am a small quart eater)Is we. nn ay ea< 0 <br /> gna ure <br /> enerato sl em s nne yp ante — 0$ 15 201 CO W <br /> InternationalDmenls ❑Eeport from U S. -4 w <br /> 16 Inle <br /> ❑Import to U S <br /> lz Date m U.S.' <br /> Trans rets nature Forex sent w 0 <br /> 17.TreMponer AcknovAedgmant of Receipl of Matenals gnaare on 1 ear N 00 CD <br /> � renspoder 1 Pnnted/Typed Name 0 TI TI TI <br /> Oon <br /> a Isidro Martinez <br /> 5tgnalure 2/ /D m m m <br /> aTranaDoner 2 PrinledRyped Name / <br /> 2 /yr.�•t!/�ra'`q'. yLC(.e'ti' Ul Co <br /> to Disaapancy <br /> I ❑Residue ❑Partial Rejection ❑F"^Rte`' C3 (,Jl <br /> 19a.Discrepancy hMiiaaon Space ❑Ouantiry ❑TYPy 40 <br /> I Mani lest Relemnce Number. 8 00 00 <br /> US.EPA ID Number �..i <br /> Ito Allemalef'solify(or Generator) — --..--. <br /> J <br /> QMonth Day year <br /> LL Feat, 's Phone. <br /> W 18C.SgnatureofAftemate Facility(or Generator) � 4�:, 4�:, <br /> O O O <br /> a O O O <br /> z00 <br /> 19 Ha_nfous Waste Report Management Method Codes(I e„codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> t 2 3. .Zl <br /> u `° <br /> 0 <br /> Id FaalAy r a rator.Certification of recelpt of hazardous materials covered by the manifest exce as noted in Item t a M Da ye r <br /> Pnntel Tit K amu Signature <br /> TION STATE(IF REQUIR <br /> (D EPA Fam 0012(Rev 5)Prev s e Itlons are obsol DESIGNA E ILITY TO DESTINA <br /> CDCD <br /> r.nnn.c.n nnnn.c.n <br /> 0 nn. ..� r,r•.annr.n-r u W <br /> CY) <br /> O <br /> v <br /> v <br />