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IPlease print or type.(Form designed for use on elite I <br /> 9 (12 pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emer�c enc Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000409953 1 877,,77Y2669 012121379 F L E <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Banfield Pet Hospital #1184 Ban field Pet Hospital#1164 <br /> 2098329373 2477 Naglee Rd 2477 Naglee Rd <br /> Generators Phone: Tracy, CA 95304Tracy, CA 95304 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNS000110924 <br /> 7.Transporter 2 company Namee�" • U.S.EPA ID Number �( S <br /> 8.Designated Facility Name and site Address d 1 5 e n Ur � <br /> y ! U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone:7755752760 NVD980895338 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> liquids, organic, n. o. s. 1 CF 00010 P 311 005 024 <br /> X UN2810, Waste Toxic, <br /> 0 (Barium, M-Cresol), 6. 1, PG II, ERG#153 <br /> z 2. <br /> D026 61309 279 <br /> w <br /> c� <br /> 3. <br /> 4. <br /> I <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> 1. 110583(Rx Toxic Liquids) <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 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)(if I am a small qua generator)is true. <br /> Generato`r'c/Offeror's Printed/Typed Name Signature Month Day Year <br /> S * 104 1 PA loll A <br /> -1 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> Transporter 1 Printed/I yped Name SignatureMonth ay Year <br /> O I I <br /> aIsidro <br /> PA 61 <br /> z Transporter 2 PrintedfTyped Name Sionat- Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceEl ❑ 1 ElFullRejection <br /> Quantity El Type El Residue Partial Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU p 1• 2. 3. 4. <br /> 20.Designated Facility Owner or 0 erator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> i lure � <br /> 7th <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 8700-22 12v3 .CA40000170 541060364 0412�1 <br />