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Form Approved, OMB No. 2050-0039 <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) — p <br /> 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAR000235200 8009246804 010 7 8 8 7 0 6 F L E <br /> WASTE MANIFEST <br /> 5. Generators Name and Mailing Address Generator's Site Address (ii different than mailing address) <br /> CVS #9861 CVS#09261 ' <br /> 2093695853 100 West Lodi Avenue 100 West Lodi Avenue <br /> Lodi , CA 95240 Lodi , CA 95240 <br /> Generator's Phone: U.S. EPA ID Number <br /> 6. Transporter 1 Company Name <br /> Stericycle Specialty Waste Solutions Inc MNSOOOI10924 <br /> 7, Transporter 2 Company NameS <br /> U. . EPA ID Number <br /> 8, Designated Facility Name and Site Address StertcycTe , IIIIIIIU.S. EPA ID Number <br /> 2670 Executive Drive <br /> Indianapolis , IN 46241 <br /> Facilit>rs Phone: 3175245617 I N 8000 1 1 0 1 97 <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, rNo <br /> ners 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) Type Quantity Wt.Nol. <br /> X 1 . UN3248 , Waste Medicine , liquid , flataetable , CF' 00001 P 31 � D001 <br /> III toxic , n . o . s . ( Alcohol ) , 3 6 . 11 PG I1 , ERG# <br /> Z 2. j <br /> LU <br /> 1 <br /> 4* s <br /> i4. Special Handling Instructions and Additional Information 1 . 102966 ( RX Stat a Regulated ) <br /> I Million <br /> UNIFORM <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeledlplacarded, 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 large quantity generator) or (b) (if I am a small quantity generator) is true, <br /> e <br /> Month Day Year <br /> Gen 10 emes nnt@TrypR Name t <br /> W � I'+\ 1 @A 201 <br /> a 16. International Shipments ❑ Ex rt from U.S. r Port of entrylexit: <br /> F ❑ Import to U.S. Po <br /> z <br /> Transporter signature for exports only): Date leaving U.S.: <br /> UX 17. Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name 71,naie ontay ear <br /> a Johnny Harper ( 1 � y 20 7 <br /> Cl) _ , re Month Day ear <br /> Transporter 2 PrintedrTyped Name � ��,/ <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space El Quantity El Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) <br /> V <br /> LL Facili s Phone: Month Day Year <br /> U0 18c. Signature of Alternate Facility (or Generator) } <br /> Q <br /> Z <br /> y 19. Hazardous Waste rt Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and cling systems) <br /> 3. 4' <br /> O 1 • f 2 'x <br /> 20. signaled Facility Owner or Operator: Ce ' tion of receipt of hazardous materials covered by the nffes pt as noted in Item 18a Month ay. <br /> Yp , <br /> Sig 4 tl (J ' : <br /> P ' le yped NameLk I <br /> Fir <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) { <br /> A <br /> D "IlachoI i b . . '} not nnrxnn � s. <br />