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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-003 <br /> UNIFORM HAZARDOUS 1•Generator ID Number2.Page 1 of 3.Emer enc Res onse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CRL000409951 1 877�7726�69 010868634 F L <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Banfield Pet Hospital #1188 Banfield Pet Hospital#1188 <br /> 2094740119 10520 Trinity Parkway 10520 Trinity Parkway <br /> Generator's Phone: Stockton, CA 95219 Stockton, CA 95219 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address , U."S.EPA I umber <br /> 2095 Newlands Dr. East <br /> Fernley, NU 89408 <br /> Facility's Phone: 775575760 NVD980895338 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> X 1 UN2810, Waste Toxic, liquids, organic, n. o. s. 1 CF 00021 P 311? [)005`D024 <br /> o (Barium, M-Cresol), 6. 1, PG II, ERG#153 <br /> D026D009U279 <br /> w X 2UN3249, Waste Medicine, solid, toxic, n. o. s. 1 CF 00002 P 311 D010D011 <br /> (Selenium, Silver), 6. 1, PG II, ERG#151 --- <br /> 3L -3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 110583(R x Toxic Liquids) 2. 109331(Rx Toxic Solids) <br /> 15. 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 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)(iriNl a small anti nerator)is true. <br /> G /Offro s P'n d[Typed Name re I monthar ay e <br /> �, 05 23 201 <br /> 1 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/ex . <br /> Z <br /> Transporter signature for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name ignature Month Day Year <br /> a Johnny Harper 1 051 23120111 <br /> aIf <br /> Transporter 2 PrintedlTyped Name SignatuMonth Day Yeaf, <br /> F /U, /u!_ / (/ff/ <br /> 18.Discrepancy 19r=;V J <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 Facility's Phone: <br /> LO 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> tQ <br /> Z <br /> 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ G 1. 2. 3. 4. <br /> V�\\-\� I IVA <br /> (- 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name. SignatureDay Year <br /> Mo <br /> EPA Form 8700-22(kev.3- Previous editions are obsolete. DESIGNATED FACILITY/f0 ESTINATION STATE(IF REQUIRED <br /> 8700-2212v3 CA40000170 541 368 041117901 M PT 18 SD052318 <br />