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REVIEWING A MANIFEST BEFORE SIGNING
<br /> REVISE EL MANIFIESTO ANTES DE FIRMAR
<br /> Verify this is your Store Address Verify this is your Store EPA ID#
<br /> and Contact Info Verifique su EPA ID#
<br /> Verifique su direcci6n Manifest#
<br /> e informaci6n de
<br /> Fbeee print orpe.IForm des'ned for use an e9k t2 Fam Approved.01616 No. M a n ifi esto#
<br /> contacto UNBORN HAZARDOUS 1 Ce a Ha ID NumbY 2 Pape t of 7.1a aryl aryy w,a,. hn T u4 np NumW
<br /> w NAND T C A R N 0 0 1 2 3 4 5 6 1 (s66)see-asp_ 0 0 6 0 2 4 8 41 JJK
<br /> 5C--W.Nv.WUb VAM— Exemplar#7468 f$M1 "'"tl nn ipi0°"I Emergency
<br /> Attention:Gary Haywood 810 East is Response Phone
<br /> (415)244-1146 San Francisco,CA 94134 p
<br /> 8 T-.",I (make certain one
<br /> Transporter Name eTrerePalar,Canpa,y wRe DS EPA ID Mmear
<br /> p S En,*onmental Solutions M N S 0 0 0 1 0 0 9 2 4 is listed)
<br /> &EPA ID(make certain • US EPAIDN-4Telefono de respuesta
<br /> there is an entry) ante Emergencias
<br /> �•� `a Acme Recycling 8 Disposal US EPADNaor
<br /> Nombre del 8520 Ivey Lane
<br /> transportador y EPA ID Atlanta,GA 30019 Disposal Facility
<br /> F (878)424-7215 GAD 0 0 0 1 2 8 9 7 8 &EPA ID
<br /> W. 9e,U.S.DOT 13-0 n r-",n;P'W Srto q Nana,H..M CM 10NmbY, it ud
<br /> An "X"or"RQ" M1 wpd&vc or yp � � "W�Cd. (make certain one
<br /> � -UN1950,Waste Aerosols, flanmeble 2.1,PG,ERG-126 IS Iste
<br /> )
<br /> indicates there is � )
<br /> DOT Hazardous Centro de
<br /> zUN1993,Waste Flammable liquids,n.o.s. (ethanol,methan disposici6n y
<br /> Material x PG 11,ERG-128 IVEPA ID
<br /> Una "X" o "RQ"
<br /> indica que hay �UN1760,Waste Corrosive licuids,n.o.s. (sodium 01 j.
<br /> materiales peligrosos x sodium silicate)8,PG Il,ERG-154AIL Make certain
<br /> A Nott'-Hazardous,Non-Regul s 561 EPA or State
<br /> Proper Shipping Waste Codes
<br /> Description Area i 14'SpdWftd*Vequ�m.rd are Listed
<br /> 1.5194
<br /> (must be filled in) 2 5192 Confirme que el
<br /> Area dp a,e descri ci6n 3. g
<br /> 5195 EPA o los c6di os
<br /> del env(o(debe ser > �tr;�a'•,°as.°`EERDAsceRTIFIunoN:Inad. ^e�s. `aor.an.�.�..w. �•.r,die. ^q�.p�p«., npn....d..a�..ePp�• de residuos esten
<br /> naked""'r:^.yaa+dx,eM voln al mPer.4npngr mndMrf110r►Y,yM+m70Fg bepptada YamraeaWend 9o,n^nw+W n94.Eona XWWI W lra M P,bry
<br /> completa) P.00nr urns oun,mnewngnm.m abmtobern.an..e"»d[PAaAana..epn mca..a enunclados
<br /> I ceMSL xt Re wale r,w,mvatim vlaEanant d•f d n eo CFR2e2M(WIems Hpaao'M' IGl fdl am nua„4Ir:;':=Wr+l ie e,+
<br /> Grcryq(sL"'wr/.P-nW7yW Nan- MonC ”
<br /> L.. lot' Stericycle
<br /> Transporter °�• ^ ❑aaPa bus ❑epneoau. Poem <,:
<br /> Tw aN 5naa<a P-P"WO Dab,;„, Technician
<br /> Name& ,,LaupdaAtlnaabdp IfrmRacePmM.aNY ._.........._._......... (to be signed once
<br /> Signature TnnpaMt Nara "; '4 Yw
<br /> (Required prior to ��„ ( manifest is reviewed
<br /> departure from M.° D" Y. and information
<br /> your store) r is Da-W y confirmed)
<br /> Nombre del I 18a D-Wawy'n"=""om° ❑ h ❑T,, ❑Ram,. ❑P,rwM* , ❑F°,N u Nombre y firma
<br /> transportador y firma del representante
<br /> 180.AeeP"ra FacAty(a Gmm I U.S.EPA Nwbw de la tienda
<br /> F eP a Legend:
<br /> 18c,5gwuremMa,MeFa:lty(a Gereemd Mann DY Year
<br /> Disposal Facility vyafb Items to Verify
<br /> Name&Signature a,
<br /> 19 Hor
<br /> aAtnRepot M.n.q~MOtl d Codes(to..oadea fah-6m emt.9saa,ea.6apwtl.aM,.oY' v"% OI
<br /> (included on final copy 0 2
<br /> Informaci6n para
<br /> received approximately W..Deug Facery0Awa0pxabcta•Ncaeon verificar
<br /> 30 days after service) 17
<br /> Nombre y firma del E NIF-3u� a,+ro ATED FACT ESTINA WE ae ulpl ij4 l+ • Signature
<br /> centro de disposici6n X152 14T�rNA QFA4 N F! Required
<br /> Firma requerida
<br /> The Leader on Duty should review the information on the Manifest but should not sign any portion of the Manifest.
<br /> *Signed manifest copies must be kept on file in the Training and Compliance Binder for a period of 3 years.
<br /> Stericycle"'
<br /> The Stericycle Guide to Potentially Hazardous Material Management 4.0.0
<br /> Gula de Stericycle Sobre el Manejo de Materiales Potentcialmente Peligrosos
<br /> ©2017 Stericycle,Inc.All rights reserved. DD6PTS00-02-0317 Environmental Solutions
<br /> DDOTS00-02-0317.indd 10 3/17/2017 3:41:27 PM
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