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Please print or type,(Form designed for use on elite(12-pitch)typewriter.) ER Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CA 000259515 1 8009246804 011434309 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> , CVS. (SIS) #17412 CVS (SIS)#17412 <br /> 8092425041 16858 Golden Valley Pkwy, Suite B 16858 Golden Valley Pkwy, Suite <br /> Generator's Phone: Lathrog, CA 95330 Lathro <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc MNS0012111121924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> a <br /> 8.Designated Facility Name and Site Address-St er i cyc 1 e, Inc. U,S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> Facillt es Phone: 3175245617 11NRI0112110110197 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wtivoi. <br /> X 1UN3248, Waste Medicine, liquid, flammable,, i CF 00001 P 311 D001 <br /> 0 toxic, n.o. s. (Alcohol), 3 6. 1, PG II, ERG# <br /> 131 <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 102966(RX State Regulated) <br /> 15. GENERATOR'SIOFFEROR'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, <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 the attached EPAAcknowledgment of Consent. <br /> 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 quan' eretor)is true. <br /> enerato sl eros Pnnt ype Name rgna re on ay ear <br /> Q 08 15 201 <br /> 16.Intemational Shipments <br /> ❑Import to U.S. ❑Export from U.S. Pori o n d: <br /> Z <br /> Transporter signature forexports only): Date n U.S.: <br /> Cd 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printedrryped Name Signature Month Ua-y--Te-a-r <br /> a Isidro Martinez 1 08 5 201 <br /> U) ayYear <br /> Transporter 2 PrintedfTyped Name SigU� ��wCl�' nature o� <br /> E- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> ►Q Facility's Phone: <br /> W 18c.Signature of Ntemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. <br /> 141 <br /> 2. 3. 4. <br /> 44"306419tad Facility Own r or ,perator.Certification of receipt of hazardous materials covered by the manifest ex as noted in Item 1JA <br /> Prinwary ame Signature M N�l <br /> 1 A 1 <br /> 71 <br /> EPA Form 700-22(Rev.3 5) Priv' s e itions are obsolete. DESIGNATE ILITY TO DESTINATION STATE(IF REQUIRED) <br /> 8700-2212v3 CAL20090641 541027117 041180487 M PD081518 SD081518 <br />