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RECEIVED BY SJC EHD ON 5/3/2019 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) '. 0Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST S13092'4 ,"�,0 4 011385012 F L E 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) CVS (SIS) #1t68 56 CVS (SiS)#16356 098239382 280 .Spreckels Ave, Suite B 280 Spreckels Ave, Suite B I -3rttsc�. �Ai 5_3 -t LA Generator's Phone: � `�" I i v e i` -, 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialt4 Waste Solutions Inc jVZ000110924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 095 Newlands Br. East Fernley, Not 894�8 NVD98 I557;2760 &�35338 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. ieVa ae t UE LEst Lorit:inecl. IL`s., t11 f �1 F'0U oMedicine, solid, toxic, n.o. a. (Warfarin), _.R------ 6. i. PG 11. ERG#151 zDC 2. C , Waste toxic s0 t S, Organic, n. o. s. � 3 11 N07-MIT (Chromium. Selenium) . 6. 1. PG 11. ER(3#154 3. 4. 14.Special Handling Instructions and Additional Information i•_ .i < a z. ;p 1 kk e e t 1 0 e n O 2 Cee, t i s. , 1.00196(R.y To),ic Solids 15. GENERATOR'S/OFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmentanregulat, xport shipmentand I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Ackn t of Consent. I certify that the waste minimization statement identified in40 CFR 262.27(a)(if I am a large quantity generator)or if I a small quantity genera Gen to0 ror's rintedffyped Na bigna Month y Year 1 .International Shiplents Z ❑Import to U.S. ❑Export from U.S. ort of e exit: Transporter si nature for exports only): Date le vin U .: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name gna ure onth Uay Year a Anthonv Mack I _ I '. I - pole ZTransporter 2 Printed/Typed Name t Month Day Year 11 -Vl dIt 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantit ❑Type Y yp ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U a LL Facility's Phone: UO 18c.Signature of Alternate Facility(or Generator) Month Day Year ZZ 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 1. 1 2 3• 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials wvered by the manifest except as noted in Item 18a PrintedlTyped NameSignature Month Day--/M , -)K-- 1 !�� p,�, Year \-��r L(p ( � EPA Form 8700-12(Nev.' 0 revious editions are obsolete. DESIGNATED FACILITY ESTINATION STAT (IF REQUIRED) B-1700 22_1 cv3 CAL. 171 S fE,s l +1 27,315 041192109 M PE i s 0082'318