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<br /> 0 12- itch writer. ERIN Form Approved, OMB No. 2050.0039
<br /> Please pont or type. (Form designed for use n elite ( p ) type )
<br /> UNIFORM HAZARDOUS 1 , Generator 10 Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number
<br /> WASTE MANIFEST CAR000235200 2 80092468Q 010788708 F L E
<br /> 5, Generator's Name and Mailing Address Generator's Site Address (ff different than mailing address)
<br /> CVS #9261 CVS#09261
<br /> 2093695853 100 West Lodi Avenue 100 West Lodi Avenue
<br /> Generators Phone: Lod i , CA 95240 Lodi , CA 95240
<br /> 6, Transporter 1 Company Name U.S. EPA ID Number
<br /> Stericycle Specialty Waste Solutions Inc MNSOOOI10924
<br /> 7, Transporter 2 Company Name y U.S. EPA ID Number
<br /> 8, Designated Facility Name and Site Address 21st Centrury EMN , LLC U.S. EPA ID Number
<br /> 2095 Newlands Dr . East
<br /> Fernley , NV 89408
<br /> Faciitys Phone: 7755752760 NYD980895338
<br /> ga 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 WtNoi.
<br /> I �T
<br /> w
<br /> 1 . UN2811 , Waste Toxic solids , organic , n . o . s . i CF 00002 P 31 D00 D01
<br /> o ( Chromium , Selenium ) , 6 . 11 PG II , ER8# 154
<br /> Z X2, UN3249 , Waste Residue Last Contained , 1 CF 00001 P 31 P00
<br /> Medicine , solid , toxic , n . o . s . ( Warfarin ) ,
<br /> 6als PG III ERG# 151
<br /> X 3. UN3266 , Waste Corrosive liquid , basic % i CF 00005 P 1221 D00
<br /> inorganic , n . o . s . ( Sodium Hydroxide ,
<br /> Potassium Carbonate ) , 8 , PG II , ERG# 154
<br /> X4- UN1950 , Waste Aerosols 2 . 1 , ERG# 126 1 CF 00005 P 214 Deal ,
<br /> 14, Special Handling Instructions and Additional Information 1 . 100196 ( RX Toxic Solids ) 2 . 101079 ( Residue weight does not
<br /> exceed 0. 0436 lbs ) CNT : 37 3 . 100199 ( Corrosive Basic Liquids ) 4 . 100201 ( Aerosols ,
<br /> Flammable ) 3 �� � C
<br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare th the contents of this consignment are fully and accurately escribed above by the proper shipping name, and are classified, packaged,
<br /> marked and labeledtplacarded, and are in all respects in proper dton 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 EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if I am a large quantity r) or (b) (if I am a smz
<br /> o4quantity generator) is true,
<br /> er rsl em s Print yped Name a u n ay ear
<br /> L /JP1 0 2017
<br /> 16. ational Shipments
<br /> ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br /> Z Trans rter signature for ex its onl Date leavi U.S.:
<br /> W 17. Transporter Acknowledgment of Receipt of Materials
<br /> Transporter 1 Printedffyped Name gnature on ay ear
<br /> C)
<br /> Johnny Harper 1 0 2017
<br /> U) Transporter 2 Printedrryped Name re Signature on Day ear
<br /> 18: Discrepancy
<br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection
<br /> Manifest Reference Number:
<br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number
<br /> J
<br /> U
<br /> LL Facil' s Phone:
<br /> C@ 18c. Signature of Altemate Facility (or Generator) Month Day Year
<br /> Q
<br /> Z
<br /> y19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems)
<br /> G 1 . 2. 3, 4
<br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16
<br /> Pdntedflyped N me Signature Month Day Year
<br /> j o I Ell
<br /> EPA Form 8700.22 (Rev. 3:05) Prevlous editions are obsolete . DEtlGrFACILITY TO DESTINATION S ATE (IF REQUIRE
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