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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) ER r r Uc _ Form Approved OMB No 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2 Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAR000235200 �" 8009246804 009156089 FLE <br /> 5, Generator's Name and Mailing Address Generetar s SdeAddress (if different than mailing address) <br /> CVS #9261 CVS#09261 . <br /> 2093695853 100 West Lodi Avenue 100 West Lodi Avenue <br /> Genomtor'sPhone: Lodi . CA 95240 Lodi , CA 95240 <br /> 8. Transporter 1 Company Name US EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc MNS000110924 <br /> 7. Transporter 2 Company Name U.S EPA ID Number <br /> k S �� J8G31�3 <br /> 8. Deslgnnted Facihry Warno and Site Address St er i c y c 1 e , Int . U.S. EPA 10 Number <br /> 2670 Executive Drive <br /> Indianapolis , IN 46541 <br /> FacrBtesPhone, S INRO ViiiVJ197 <br /> go 9b, U.S, DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 11 . Total 12 Unit 13 Waste Codes <br /> HM and Packing Group (if any)) No Type Quantity wiNol. <br /> a X 1 . UN3248 , Waste Medicine , liquid , flammable , i CF 00001 P 31 D00 <br /> toxic , n . o . s . ( Alcohol ) , 3 6 . 1 , PB II , 6RB#LU <br /> j <br /> M <br /> 2. <br /> W <br /> 1 <br /> 3. <br /> 4. <br /> 14, Spa*[ Handling instructions andAdditlonal information 1 . 102966 ( RX State Regulated ) <br /> 15, GENERATORIS[OFFEROR'SCERTIFICAT(ONt I hereby declare Wl 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 propetoonddlon for transport according to applicable international and national governmental regulations, If export shipment and tam the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement Identified in 40 CFR 262,27(3) (if l am a large quantity generator) ar(b) (it tam a small quantity g erator) Is We <br /> Worslofforors Pruntedayped Name I /J( Month Day Year <br /> Mu2 6017 <br /> .a 16. Inlornahonal hipments <br /> Import to U S, El Export from U.S. oil of enlrylewl <br /> Trans rtersignature for exports ord • Dale leaving US <br /> 17. Tmnspodor Acknowiedgmenl of Receipt of Materials <br /> Transporter 1 Pnnledfryped Name ignature Month Day ear <br /> a4 Johnny Harper Z40,1 21 '2'017 <br /> QTransporter 2Printed/Typed Name ,r Signature Month Day Year <br /> /" #�) I d", /7 <br /> 10, Discrepancy <br /> 18a, Discrepancy Indication Space Quantity ❑Type ❑ Residue lection Rejection <br /> ❑ Partial Re ❑ Fu8 <br /> Manifest Reference Number. <br /> 18b. AlternateFaahly (or Generator) US EPA toNumber <br /> act <br /> ict <br /> FacuUt s Phone: <br /> M 183, SignaluroofAitemateFacUity (orGenetator) Month Day Year <br /> Q <br /> x <br /> zardous aste Report Management Method Codes (I,o„ codas for hazardous waste treatment, disposal, and recycling systems) <br /> 3. 4 <br /> 20. led Facility Owner or Operator: lication of receipt of hazardous materials eDvered by the,Pqijdstyceplag noted in Item 18a <br /> r19dfT)Vod Name re ,L''�✓ Month y r <br /> Llr C <br /> EPA Form 6700.22 (Rev. 3.05) Previous editions are obsolete, DE5IGNATI;D FACiI tTY i0 DESTINATION STATE (IF REQUIRED) <br /> 8700-22, 12v3 CAL20090641 58866 045853841 M PDO52517 0052517 <br />