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Reasepdnlortype.(Form desinad for use on elite(12-pith)Vaill 1111111111 pillIN III NO Form Approved.OR No.2050-0039 <br /> UMFORM HAZARDOUS 1.Generator ID Number 2,Pagelof 3.Enewricy Response Phone 4.Manifest radrlgNumbar <br /> Will EMANIFEST CA0001007749 t 8775772 008664703 FLE <br /> S.Genaaloh Narrial MailingAddress GemreWls SA*A mss It different Nal mal add2aa) <br /> Rite Rid #6004 Rite Rid#6004 <br /> ,'; 4175 900 North Main Street 900 North Main Street Cardoza C <br /> + 'riGeoe sRpne: Manteca, CR 35331, Manteca. LR 95336 <br /> ( �sner- mpany ams U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 'Tranegonla 2 Company Name U.S.EFAID Number <br /> ?187odeagnmet,FeaLb'Name and q1ne Aadiness lien8ral nMatm.ntal Nqt, LL'_. U.S EPA IO Number <br /> 11855 White Rock Road <br /> 8ancn0 LordoMar CA 95742 <br /> Fadi cPhone: 916751098'n CRD9808B4e83 <br /> ger all 0.9.DOT Oesadption(Indudmp Proper Shipping Name,Hazed Class,ID Number, 10,Containers 11.Total 12.U0 <br /> HM end Pal Group(if any)) No. Type Quantity YA.NoI, 13.WmteCaOee <br /> 1,Non REM naZaroous weans, soM (NeY'sonal. hays ., 2103bk"I p 331 <br /> Gp Products), <br /> �Wkaa 2. <br /> cY <br /> 7. <br /> 4. <br /> 14,SpeGm Handling lnstnxtiors end Addliunallnformetbn 1. 1007o9(CR State Regulated Solids) - <br /> 15. OENERATORWOFFEROR'S CERTIFICATION: I hereby declare Net the content ofthi9 amnsignmanl are fully and adonalely described abmm by the proper shipping name,and are Classes.packaged, <br /> maned and labeledryhareNed,and are F all respect In proper coxii0on for Intel soording to appgreble pvemmentl regulations.It export shipment and l sm the primary <br /> Exporter.I callfy Nat the war-tents of this consignment conknn to the Ions tithe al fall EPAAckywglnl of Consent. <br /> I redly that the wade minimimlim statement Identified in 40 CFR 25227(e)tel l em alarge quart' generator (f l am a small quantltyga tor)ia We. <br /> ret em a nl petl Nam Igna n ay ear <br /> li 11 201 ' <br /> � 16. mations Shipment ❑Importb U.9. ❑ hon U.S. on danbyletlC <br /> Lens Hers'nature for ex ark anti Dale wrall U'S'; <br /> 17.TraeapoderAcknowledgmem or Receipt 0Metakls <br /> r porter 7 nkdRyped NameSigns o ay car <br /> 2 rrlstother Rlmanza 11 i1 01 <br /> N <br /> Z R rtef2 Pdnkdllypad NamebigradonsMill <br /> 1,7/y ear <br /> /(O <br /> 18. <br /> 01sempAcy <br /> 1 Be.Disompan y Irxllretlon Spare ❑ OuerMry ❑Type ❑Resklue ❑Parba Rejection ❑FAI Rejection <br /> Man fast Reference Number, <br /> IBb.Alternate Faciliy for Gottshall U.S.EPAID Number <br /> J <br /> e1 <br /> LL FaciF a Plpne: <br /> 4w 18c.5gnaaremAltemafelonilly(or Genemkd Monty Day Year <br /> 2 <br /> iZ <br /> 19.HazardpusWaste Report Management Melnd Caks(Ia.,mdmio haiatlpuswaatabeaimem;disposal,and recYd'rc9 ayetms) <br /> 3. 4. <br /> yl <br /> :•-( •:. .Qgsjinstead Fi lldy Omer or Operator:Confiscation of receipt of hazardous mmenals covered by the manifest except as noted in Item 18a <br /> Signature Monty Day .� <br /> Rey.3-05) reviolus editions are o solele. G TED FACILITY TO DESTINATION STATE(IF <br /> p o rtx. <br />