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Please print or type. (Form designed for use on elite (12-pitch) typewriter) <br /> ERTI Form Approved. OMB No. 20%0039 <br /> 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> UNIFORM HAZARDOUS 002 <br /> WASTE MANIFEST cAR061065 1 8009246804 . 011434014 F L E <br /> 5T, Generators Name and Mailing Address Generator's bite Address (if different than mailing address) <br /> CVS ( SIS ) # 16294 CVS ( SIS ) # 16294 <br /> 2093699371 2355 W Kettleman Ln , Suite B 2355 W Kettleman Ln , Suite B <br /> GeneratofsPhone: Lodi ,, CA . 95242 Lodi , CA. . 95242 . <br /> . Transporter ompany Name U.S. EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNSOOOI10924 <br /> 7, Transporter 2 Company Name EPA ID Number <br /> rno a��Q <br /> 8. Designated Facility Name and deA reury , U. PAID r <br /> 2095 Newlands Dr . East <br /> Fernley , NV 89408 <br /> Facility's Phone: 7755752760 NY 895338 <br /> ga 9b. U.S. DOT Description (including Proper Shippng Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wtivol. <br /> X bN3249 , Waste Residue Last Contained , 1 CF 00001 P 311 P001 <br /> o Medicine , solid , toxic , n . o . s . ( Warfarin ) , <br /> 9 6 . 1 PG II ER13# 15 <br /> X bN2811 , Waste Toxic solids , organic , n . o . s . 1 CF 00004 P 311 D007 DOM <br /> (Chromiva , Selenium ) , 6 . 19 PG II , ERG# 154 <br /> 3. <br /> 4. <br /> 14, Special Handling instructions and Additional Information 1 . 101079 ( Residue weight does not exceed 0 . 0436 lbs ) CNT : 13 2. <br /> 1001.96 ( RX : Tox1c Solids ) <br /> 61ntenlnWal <br /> ATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accu tely described above by the proper shipping name, and are classified, packaged, <br /> and labeledlplacarded, and are in all respects in proper condition for transport according to applicable international nd national governmental regulations, if export shipment and 1 am the Primary <br /> r, I certify that the contents of this consignment conform to the terms of the attached EPAAdknowledgment of Cons t. <br /> that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (it I ata small quantity generator) is true. <br /> eror's nntedlry Name rgn ay Year <br /> 09 0712011 <br /> [�jSlItipments Import to U.S. ❑ Export from U.S. Port of entrylexit <br /> i— <br /> Trans odor signature for exports only): Date leavin U.S.: <br /> W17, TrensporterAcknowledgment of Receipt of Materials <br /> Month <br /> LU Transporter 1 Printed/Typed Name -Signature ay Year <br /> a . Isidro Martinez s <br /> Tran iter Printedrtyped 1 f,6 <br /> 84 <br /> 18. Discrepancy <br /> 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> U.S. EPA 1D Number <br /> 18b, Altemate Facility (or Generator) <br /> J <br /> V <br /> LLadli 's Phone: Month Day Year <br /> WE 18c. Signature of Alternate Facility (or Generator) <br /> Q <br /> Z <br /> 19, Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 3. 4. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a Month Day Year <br /> P U4 <br /> Printed/fyped Name Sig re_ <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br /> „ 8'100-22�12v3 CALc @09.0641 241027123 041196803 _ M PtfOt9ati <br />