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i Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000409951 1 8775772669 011387069 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Banfield Pet Hospital #1188 Banfield Pet Hospital#1188 2094740119 10520 Trinity Parkway 10520 Trinity Parkway Generator's Phone: Stockton, CA 95219 Stockton, CA 95219 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Design ed FacilityName and SiteAddress 21st Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone: 7755752760 NV 980895338 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. �( UN2810, Waste Toxic, liquids, organic, n. o. s 1 CF 00003 19 311 D005 D024 o (Barium, M-Cresol), 6. 1, PG II, ERG#153 � D@26 D009 U69 z 2. uu c� I 3. 4. 14.Special Handling Instructions and Additional Information 1. 110583(R x Toxic Liquids) 15. GENERATOR'S/OFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. 1 Generato r s Pn ed/Typed Na Signature on ay ear 4 1 %T I"-�_-> I -- 1 16.Internationa ipmen 3 2 18 H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI � Transporter 1 PrintedfFyped Name Signature ort ay Year a Kristop er Almanza I ( I 03 t2 2@18 ZTransporter to yped 5ame / Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1. 2. F3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year t EPA Form 8700-12(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILI T DESTINATION STATE(IF REQUIRED)