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<br /> 4 GENERATOR ).. I UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />CAR000245092
<br />2. Page 1 of
<br />2,
<br />3. Emergency Response Phone
<br />8775772669
<br />4. Ma rinitt §mgr2 5 3
<br /> F L E
<br />Generator's Name and Mailing Address Attn:Site Safety Manager Generator's Site Address (if different than mailing address)
<br />AMAZON.COM SERVICES LLC (OAK4) AMAZON.COM SERVICES LLC (0AK4)#0
<br />(209) 604-4148 1555 N Chrisman Road 1555 N Chrisman Road
<br />Generator's Phone: Tracy, CA 95304 I TrAPy 7 17A 9911714 Transporter 1 Company Name U.S. EPA ID Number
<br />Stericycle Sperialty Waste Rolutinng inr I i'r1N9171171G11 1 0924 Transporter 2 Company Name U.S. EPA ID Number
<br />7--- i -c:14TA- IWC-)7Z ),4- -77z-47 ,6 Pr C I 6 M 6 1 , - 0).-100Z c. Ai 0 ? 1 Designated Facility Name and Site Address 21st Cent ury EMN, LLC U.S. EPA ID Number
<br />2095 Newlands Dr. East
<br />Fernley, NV 89408
<br />Facility's Phone:7755752760 I NVD980895338
<br />Pa. Pb. 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 WINol. 13. Waste Codes
<br />X 1111\11..%, Waste Carbon, activated (Carbon,
<br />Activated), 4.2, PG III, ERG#133
<br />1 DM 00078 P 141 D001 D003
<br />X PO, NA3077, Hazardous waste, solid, n.o.s.
<br />(Mercury), 9, PG III, (D009)
<br />1 DF 00024 P 181 D009
<br />X WN1325, Waste Flammable solids, organic, n.o.
<br />s. (Acetone, Charcoal), 4.1, PG II, ERG#133
<br />1 DF 00072 P 331 D001 D006
<br />D035
<br />X WN2903, Waste Pesticides, liquid, toxic,
<br />flammable, n.o.s. (Aromatic Hydrocarbon,
<br />Permethrin), 6.1 (3), PG II, ERG#131
<br />1 DF 00202 P 331 D001
<br />Special Handling Instructions and Additional Information 1. 1 1 1585 (Natural Moco Bamboo Charcoal) 2.109733 (Broken Light
<br />Tubes & Bulbs) 3.109743(Flammable Solid LoosePack) 4.109787(Pesticide Liquids Loosepack)
<br />(br)(br)
<br />GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged,
<br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national govemmental 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 large quantity generator) or (b if I am a small quantity generator) is true.
<br />Generator's fferors Printed/Typed N
<br />1 Ci114) WCt .
<br />
<br />Signatue Month Day Year
<br />j , I b\ 112 I 07 V020
<br />....1
<br />i- 3
<br />teona Shipm n s m i
<br />Import to U.S. Export from U.S. Porto 1 .
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17, Transporter Acknowledgment of Receipt of Materials
<br />1 Printed/Typed Name Signature Month Day Year
<br />Jesus A Marquez Ortega I I 12 I 07 V-'020
<br />
<br />Transporter 2 Printed/Typed Na Month Day Year
<br />
<br />G
<br />7
<br />P{Lt 1-c/Z.-11,1 f/C.V,--- I -", I e2- I /7 I2 4--- DESIGNATED FACILITY ---0- 18. Discrepancy
<br />Discrepancy Indication Space LII Quantity Type Residue LI Partial Rejection Full Rejection
<br />Manifest Reference Number:
<br />Alternate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone: 1
<br />Signature of Alternate Facility (or Generator) Month Day Year
<br />I 1
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1.
<br />1-1 RH
<br />2.
<br />A 1Y-1
<br />3.
<br />H1-1
<br />4.
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a
<br />Printed/Typed Name Signature /Month Day Year
<br />A-A41 ex. k L(A-ciz I At 6%1'1-6-4-- i-e* il) I i 2 lig" IA'
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM
<br />8700-22_12v3 C8275924 641016508 041951838 M PD120720 6D120720
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