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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) ER 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 2 8009246804 010685501 F L E
<br /> 5, Generator's Name aNOMPENNE
<br /> nd Mailing Address Generator's Site Address (if different than mailing address)
<br /> CVS #9261 CVS#09261
<br /> 2093695853 100 West Lodi Avenue 100 West Lodi Avenue
<br /> Generators Phone:' . Lodi CA _ .95240:-, . , Lodi A
<br /> 6. Transporter Company Name U.S. EPA ID Number
<br /> Stericycle Specialty Waste Solutions Inc IMNS121100110924
<br /> 7, Transporter 2 Company Name U.S. EPA ID Number
<br /> .lam �i i f o1P Lro
<br /> 8. Designated Facility Name and Site Add U.S. EPA ID Numbers _
<br /> Nt/ `/, 5� �
<br /> �J'V
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<br /> M/ 104 ko
<br /> Facilit es Phone:
<br /> 9a. 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 ('d any)) No. Type Quantity wt./Vol*
<br /> X : 1UN1950, ,- Waste . . Aerosols .2. 1 , ERG# 126 i BA . 00023 . P , 214 D001
<br /> 0
<br /> Z A N1 93 , Waste Flammable liquids , n . o . s . It BA 00021 P 214 D001 U002
<br /> LU
<br /> ( A1.cohols , . Acetone.). ,. . 37. PG ..: II , : ERG# 128
<br /> ttttT 3UN3077 , Waste Environmentally hazardous1 ; . .,; CF - 00002 PP� 181 "09D :substances , ;: -solid ,: : n. o . . OtMercury ). , 9 , PG
<br /> III , ERG# 171
<br /> 4 , ase >; g ers_ . , �SP+-. 13179 " ERG# 1 BA, . > . 00001; . : PtD001
<br /> 115
<br /> 14.Special ,HarWlinglnswctionsand Additlonalinformaton 1 . P-.KS-DF : 100201;( Aerosols,, , Flammable.;) : 2 . PKG-DF:: .100198 ( Flammable
<br /> . . .
<br /> Eiquids ) 3 , 1029641Bi^okanFluorescent Bulbs ) 4. PKG-CF : 101351 ( Lighters )
<br /> 154 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that 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 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 EPAAcknowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity generator) pr (b) (if am a small quang generat i, e.
<br /> Generat erorsPnnt yp Name xJ lure on ay Year
<br /> � �
<br /> 16. International Shipments
<br /> ❑ Import to U.S. Export
<br /> from U.S. Port of en lexis:
<br /> Z
<br /> Transporter signature for exports only): Date leaving U.S.:
<br /> 17, Transporter AcknowiedgmentofReceipt ofMaterials
<br /> Transporter iPrinted/Typed Name
<br /> Signature
<br /> ay Year
<br /> a ..Isidra Mart .inea ; . . . 91
<br /> z Transporter 2 Printed/Typed Name Signature Month Day Year
<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 /> V
<br /> I Fadi s Phone:
<br /> ,U 18c. Signature of Alternate Facility (or Generator) Month Day Year
<br /> Q
<br /> Z
<br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br /> O 1 ' 2
<br /> 13,
<br /> wit . Ll ( U 4. + L
<br /> 70'"N' signated Facility over or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year
<br /> Pdnted/Typed NettleSignature
<br /> EPA Form 00.22 (Rev. 3t,05) Previous editions are obsolete. DESI&&ED FACILITY TO DESTINATION STATE (IF REQUIRED)
<br /> Y;. 87.00.-�22 120CAL20090641 58866 040911642 M PD081617 SD081617
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