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16.5701 7 - ?8��q/ ER1�MJUNUJJJJJ Cc 6,- 7/ 7 <br /> Please print or type.(Form designrd for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS1 r Pae 1 of nse Phone 4.Manifest Trin Number <br /> WASTE MANIFEST Ail 9 011392821 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address 14gregt j yg3ili�g afjdfg�L <br /> CVS (SIS) #16856 Il:: ((`.i $lt+tl b <br /> 098239982 280 Spreckels Ave, Suite D 280 Spreckels Ave, Suite B <br /> Generator's Phone: Manteca, CA 95336 Manteca, CA 95336 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc hNS@00110924 <br /> 7.Imsporter 2 Com <br /> Name � � U.S.EPA ID Number <br /> s <br /> 8.De hated aci ity Name and SiteAddres-Ste i c y c 1 e, Inc. U.S.EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis, IN 46241 <br /> Facility's Phong 175245617 VNROOO 110197 <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> IJN3248, Waste Medicine, liquid, flammable, 1 I;F 311 0001 <br /> 0 toxic, n.o. s. (Alcohol), 3 6. 1, PG II, ERG# <br /> 31 <br /> Z 2. <br /> UJ <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information State e g u a e <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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a Ia b (if I am a small quantity generator is true. <br /> Generato is P inted yp dont ay ear <br /> 1 114 2PIS <br /> J 6.Intemational Shipments <br /> H• ❑Import to ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed NameSignature' Month ay ear <br /> a ristopher Almanza ' 111 114 2018 <br /> zT nsporter 2 Printed/Typed Name gna Month Day Year <br /> F �. <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ ❑Partial Rejection ❑Full Rejection <br /> ❑Type Residue <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Q <br /> LL Facility's Phone: <br /> 0 18c.SOkdure of Alternate FadW(or Generator) Month Day Year <br /> Q <br /> Z <br /> US 19.Hazardous Wapte qeport Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. <br /> 4. <br /> 20.Desig d Facility Owner or Operator:Cetion of receipt of hazardous materials covered by the m+fest as noted in Item 18a <br /> Printed ped ami rMor <br /> jay r <br /> EM Form E700-22(Rev.3-05) previous editions are obsolete. J DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> atheACWhr If.4 nL 4 Mlk-7-74 a M 411]G1=fh-1>n u nn4 4 4 X 4 h nn4.. 4 ,..n <br />