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ERl9S'7 �i6� <br /> Please pont or type.(Form designed for use on elite(12-pitch)typewriter.) 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 CAR000259515 1 8009246804 011434310 F L E <br /> 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> GUS (SIS) #17412 CVS (SIS)#17412 <br /> 2092425041 16858 Golden Valley Pkwy, Suite 8 16858 Golden Valley Pkwy, Suite <br /> Generators Phone: Lathrop, CA 95330 Lathrop, CA 95330 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address e- G e n u ry LMN, LLU U.S.EPA ID Number <br /> 2095 Newlands Dr'. East <br /> Fernley, NV 89408 <br /> Facility's Phone: 775575760 NVD980895338 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group(if an Quantity Wt.Noi. 13.Waste Codes <br /> HM 9 P Y)) No. Type h' <br /> X 1UN2810, Waste Toxic, liquids, organic, n. o. s. 1 CF 000;1 P 311 D007 D024 <br /> 0 (M—Cresol, Thimerosal), 6. 1, PG 11, E'RG#153 <br /> DOOS 0010 <br /> Z X 2UId2811, haste Toxic solids, organic, n. o. s. 1 CF 00003 P 311 D007 D010 <br /> (Chromium, Selenium), 6. 1, PG 11, ERG#154 <br /> X 3LIN3249, Waste Residue East Contained, 1 CF 00001 P 311 P001' <br /> Medicine, solid, toxic, n. o. s. (Warfarin), <br /> 6. 1. PG 11 ERG#151 �r <br /> 4. <br /> r <br /> 14.Special Handling Instructions and Additional Information 1. 10068 7(RX Toxic Liquids) 2. 100196(R X Toxic Solids } 3. <br /> 101079(Residue weight does not exceed 0.0436 lbs) CNT;19 <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 EPAAcknowledgmenl 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 )(if I am a small quantity ge is true. <br /> Generators 0 erors nnted ype Name igna ure on ay Year <br /> 081 151 201 <br /> 116.1international Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of aengV..SV' <br /> : <br /> z <br /> Transporter signature for exports onl : Date lea <br /> 1Z 17.TransporterAcknowledgment of Receipt of Materials <br /> LLIICE Transporter 1 Pr nted(fyped Name igna ure ont ay ear <br /> a Isidro Martinez 08� 15201 <br /> Z Signature Transporter 2 Printedrryped Name Mony� Day Year <br /> 18,Discrepancy <br /> 18a,Discrepancy Indication Space El 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 /> U <br /> LL <br /> Fac ilit's Phone: <br /> UJ 18c.Signature ofAlternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 0 2. g 4 <br /> F <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedrTyped Name Si lure Month Day Year <br /> h <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ''I <br /> 8700--22 i2v3 CALP0090641 541027117 041180487 �, <br />