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N <br /> ` [ 1 �I oved.OMB No.2050-0039' <br /> llf I�11 FormA r <br /> ERT USW P� <br /> Please print or typo,(Form designed for use on elite 12 pitch)typewriter.) _ b <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest tracking Number <br /> WASTEMANIFDST CAR000259515 18009246804 008597532 FLE <br /> r: 5.Goneralors ome and Mailing Address Genera. ".] <br /> tor s Slte Address(rf different than marking address) <br /> CVS (SIB) #17412 CVS (SIS)#17412 <br /> 2092425041 16858 Golden Valley Pkwy, Suite B 16858 Golden Valley Pkwy, Suite <br /> GeneralorsPhono: Lathrop, CA 95330 Lathrop, CA 95330 <br /> ETranspoderlCompanyName- U.S EPAiDNumber <br /> Stericycle Specialty Waste Solutions Inc IMNS@00110924 <br /> 7,Transporler2Company Name U.S EPAIDNumber <br /> 21st Century Environmental Of California CAR000210617 <br /> I 8.Designated Facility Name and SlloAddross Stericycle, Inc. U.S.EPA ID Number <br /> J 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> t Facility's Phone: <br /> go. Sb•U.S,DOT o4cliption(including ProperShipping Name,Hazard Class,to Number, 10.Containers 11.Tow 12.Unit 13 Waste Codas <br /> i <br /> HM and Packing Group(if any)) No. Type Quantity wtNoi, <br /> x bion RCRA hazardous waste, solid 1 CF 00001 P 311 <br /> 0 <br /> 2 <br /> c� <br /> 3. <br /> a. <br /> n <br /> 14.special Handling instructions andAdddional Information « C967(State Re 9 u 1 at ed Sa 1 i d s) <br /> 15. GENERATOR'SfOFFEROR'SCERTIFICATION:Iherebydeclarethatthecontentsofthtsconsignmentarefullyandaccuratelydesenbedabovebythepropershippmgname.andareclass&d.-pZ god, <br /> marked and labeled/placarded,and aro in all respects In propermndrbon for transport according to applicable International and national governmental regulations If export shipment and t am the Primary <br /> Exporter,I codify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minfmizotion statement tdengfied In 40 GFR 262 27(a)(it 1 am a large quanblygenerator)or(b)(if I am a small quantity generator)is true, <br /> eanerolorslOtlotorsY ntodffyped Namo rgna uro ont ay ear <br /> ,JD'j V KC[A VOS LWl' 11 04 016 • . <br /> -.r 16,Inlomo 008hfpments <br /> T Q impart to U.S. Export from U.S. Pat of entrytexrl: <br /> z <br /> Transporter sinature for"ports onl : Date leaving U.S.: <br /> 17.Transporter Acknowledgmonl of Receipt of Materials r <br /> Transporter 1 Prtiftayped Namo signa. Month Oay ear <br /> a Phil •Marciel j 11 �>7�4Qt16 <br /> Q Transport 2PdrrlodRyped a sign tur onth ay Year' , <br /> I =X� <br /> 18.Discrepancy <br /> 18a.01scroponcylndicadonSpaco ❑Quantity ❑Type ❑Residue ❑PardalRgactionj <br /> ❑Full Re edion <br /> Manifest Reference Number <br /> 18b,Alternate Faahly(or Generator) U.S.EPAID Number 3 <br /> t <br /> U <br /> Fact s Phoma: <br /> w 11k•SlgnaturoofAlIainataFadtily(arGenamtor) Month Day Year <br /> 19.Hazardous Waste Report Management MathodCodes(to.,codes forhazardous waste treatment,disposal,and recycring systems) <br /> a 1. 2, 3. 4. ; <br /> MFacgdy Owner r.Certification orrecelpt of hazardous materials covered by the marafest except as noted In Ile <br /> NPrfnled ped Namo Srgnaiure Month Day Year`'.: <br /> O rt' Br , 41 <br /> EPA Fotm 8700.22(Rev,3.05} Previous efdit ns aro obsolete. DES GNATED FA O TtNA-rinm STATE AF PEOIL11§0I4' <br />