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<br /> 4 ON EST CAR000259515 2.Page 1 of 3.Em, m M CD (% O
<br /> 1 rgency Respome Phone Fen Approved OMB No.20540039 ^
<br /> s, snd ktaikng Address 8009246804 . 4.ManHesl Tracking Numeer
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<br /> (SIS) #17412 GenemlosSdeAddrcss(ddMeeMmanmailingao011434JOE m
<br /> 16858 Golden Valle Cr � CD 3
<br /> ya41 Y Pkwy, CVS (SIS)#17412
<br /> Lathro Ye Suite 8 N
<br /> P, CA 9533''' 16858 Golden Valley 00 CD OpanyName Lathro O D
<br /> P+ CA 95330 .—.. �$teyName a SpecialtyWaste Solutions Inc D...... CLp�ompanyName MNS000110924n (� O
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<br /> 2095 f'Qe U.5—nub uebn, 0
<br /> Newlands Dr. East C:)� (D
<br /> Fernley, NV 89408
<br /> R0S.DOT5575'2760 NUD980895338 Q y
<br /> 90.par DOT Delp(d an(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers Q
<br /> sd Packing Group(d any)) t1.Total 12.Unit
<br /> No. Type Quantity WI.Not 13.Waste(odes O
<br /> UN2810, Waste Toxic, liquids, organic, n.o.s. i CF 00021 P 31 D007 D024 O
<br /> (M—Cresol, Thimerosal), 6.1, PG II, ERG#153 =3
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<br /> UtJ28fi, Waste Toxic solids, organic, n.o.s. 1 CF 00003 P 31 � D007 D010 -0
<br /> (Chronium, Selenium), 6.1, PG II, ERG#154 _ (D
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<br /> 131JN32491 Waste Residue Last Contained, i CF 00001 P 311 P001 0
<br /> Medicine, solid, toxic, n.o.s. (Warfarin),
<br /> 6-1. PG lI ERG#151 5'
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<br /> pedal Handling Instructions and Aembonauntormabon 1.100687(RX Toxic Liquids) 2.100196(RX Toxic Solids ) 3. 3
<br /> 101079(Residue weight does not exceed 0.0436 lbs) CNT.19 (D
<br /> 15 GENERATOR'S14FFEROR'SCERTIFICATION:Thereby declare that the contents of this consignment are tally and accurately described above by the proper shipping name,and are dassAred,packaged, (Q
<br /> ma,ked and labaledfplaca,ded.and are m ali respells In limper condition for transport according to applicable inlemational and national governmental regulations.1(expon shipment and I am ttt.Pinna
<br /> Exporter,I—ty that the contents of this consignment conform to Ole terms of the attached EPAAcknaNedgme(of Consent.
<br /> 1 certify that Ore waste mle're-tien statement geMified in 40 CFR 262.27(a)(If I am a large quantity genemoor)0r )(if I am a small quanGry gene is we. O
<br /> Geneool re m s nnledR ame V� igna ay .,
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<br /> 16.International s Shipments - 08 1512013 CD
<br /> _ ❑Import b U.S. ❑Export tom U.S. Partor ent xil:
<br /> Transporter nawn,for ex on Date lea n U.S,'
<br /> U17.Tmnspater Ack—ledgment of Receipt of Materials
<br /> mK Tmnsponer 1 edrTyped Name
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<br /> o. 'Isidro 11-1,1.1171Martinez oetn as rear
<br /> zQ Transponer 2 Pentedrryped Name - 08 15 201
<br /> eC /J /f Signature
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<br /> } 76.Discrepancy 71,77 1,70
<br /> I lPa.Discrepancy Indication Space ❑Quantity El Type ❑Residue ❑partial Rated. ❑Full Rejection O
<br /> �.' 186.Alternate Fao@y(or Generate) Manifest Reference Number O
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<br /> 1&,Signature otAllemale Fadliry(a Generator) O
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<br /> 13 Mazardws Ylayp Repot ManmCn1 MNhotl Codes(re..codes for hazardous waste treatment,disposal,and
<br /> � - 2 recydmg systems) �
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<br /> 2D.Designala7 FaulitY Grrtier ar 0 O (7
<br /> Prinledrr peraror Cenifiwtion of receipt of hazardous materials coverts by O,o manifest except as noted m Item 18o O
<br /> `yped Name _
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<br /> EPA Form 8700-22(Rev.3-05)previous editions are obsolete. Month NY rtar
<br /> s DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) 3O
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