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t <br /> I <br /> no oil III1H11E <br /> Please p�jnt or type.(Form designed for use on elite(12-pitch)typewriter.) E Form Approved.OMB No.2050-0039 <br /> i UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number <br /> 'WASTE MANIFEST CAR000259515 600924.6804 011387268 F L E <br /> Generaloes Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> i <br /> CVS (SIS) #17412 CVS (S.IS)#17412 <br /> 2092425041 16858 Golden Valley Pkwy, Suite P 16858 Golden Valley Pkwy, Suite :;, <br /> Generator's Phone: LA I-athirnn. CA 3 <br /> I <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> i <br /> 7.Transport r 2 Company Na U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 4St er i cyc 1 e, Inc. U.S.EPA ID Number <br /> 2270 Executive Drive <br /> Indianapolis, IN 46241 <br /> FadlitysPhone: ' �' INR000110197 <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 WtNol. <br /> X1. UN3248, Waste Medicine, liquid, flammable, 1 CF 00001 P 31 D00 <br /> 00 toxic, n. o. s. (Alcohol), 3 6. 1, PG II, ERG# <br /> Qa' <br /> 131 <br /> 2.Z <br /> w <br /> RED- <br /> A PR p 7. 101 <br /> 4. ENVIRONMENTAL HEALTH <br /> :1-F <br /> DI--l"APAPAIEN"T <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.condifion for transport according to applicable international and national governmental regulations.If export shipment and lam the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment ent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generale or(b)(if I a a s uanlity generator)is true. <br /> Generalors101ierors rdnledffyped Nam n ,gn t ay Year <br /> `V� /'k,1 r) 0 ' 3 20 8 <br /> ._r 16. nternalional ip en s <br /> 1 port to U.S. ❑Export from U.S. Pod of entry/ext: <br /> z Transporter signature for exports only): Date leaving U.S.: <br /> W 17.TranspoderAcknowledgment of Receipt of Materials <br /> LTransporter 1 Printedffyped Name signature Month Day Year <br /> CL Kristo her PAmanza - 8 <br /> z Transporter 2 Prinle Signalure Mon - 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 Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Mana <br /> ge <br /> ment Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJI� 1 2 3• 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the m ifestex pl as noted in Clem 18a <br /> Printed/typed Name Sgnatdr\ Month Day Yea <br /> � . 1 �� s . <br /> EPA Form 8700-22(Rev.3-05j Prev`jous edilions are obsolete- DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />