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i'U1tC►C41ti 5U1Vr=1+.ia <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 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 CAL000409953 ` X (�, 8775772669 1 012121262 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Banfield Pet Hospital #1164 Banfield Ret Hospital#1164 <br /> 2098329373 2477 Naglee Rd 2477 Naglee Rd <br /> Generator's Phone: Tracy, CA 95304 Tracy, CA 95304 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNS00101110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address Ueli EMN, ELL U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone:7755752760 INVD980895338 <br /> 9a 91 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)) No. Type Quantity Wt.Nol. <br /> X 1N2810, Waste Toxic, liquids, organic, n. o. s. 1 CF 00015 P 311 +D005 b024 <br /> o (Barium, M-Cresol), 6. 1, PG II, ERG#153 <br /> D0-2U279 <br /> LU € <br /> a ��R <br /> ( ( <br /> 3. <br /> i <br /> 4. <br /> t <br /> 14.Special Handling Instructions and Additional Information 1. 110583(RX TO x i c L i q u i d s} <br /> 15. GEN ERATOR'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) a small quantity generator)is true. <br /> Generator's/Offeror' PrintedlTyped NameignaZ <br /> Monthay Year <br /> UA a irk 24 '0i8 <br /> L� <br /> J 16.Inter ational Shipments <br /> F 1:1 - <br /> Import to U.S. Export from U.S. Port of entrylexi: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a Isidro Martinez I 110 1240 8 <br /> Transpo ter 2 Printed Typed Name g toe Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp <br /> ❑Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> C) 19.Hazardous Waste Report Management Method Codes(i.e.,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 18a <br /> Printedff ed Name Signature Month Day Year <br /> 1 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED LITY TO DESTINATION STAT'H(IF REQUIRED) <br /> 8700-22 12u3.CA40000170 . _541060364 __ 041234928, ___M_ P110P-418 SD1024i8.- <br />