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Please print or type. SCANNED <br /> t UNI ORM HAZARDOUS enerator ID Number L <br /> WAS Page 1 of 3.Emer Form Appro.205 - <br /> TE MANIFEST CALKI�7i,;2420 4 Emergency Response Phone 4.Manifest Tracking Number 0 0039 <br /> 5.Generator's Name and Mailing Address 1 (877} `r 7 7-2 669 F L E <br /> W�I Generators Site Address(if different than mailing address) <br /> greeri #2680 <br /> (209) 941-2964 15 W Harding Way Walgreen#2680 <br /> Generator's Phone: <br /> 6.Transporter 1 Cof C t 15 W. Harding Wa v <br /> mpany Name 25 " — <br /> Stiockt <br /> j U.S.EPA ID Number <br /> 7.Transporter 2 Company Name I - <br /> r <br /> U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address General Environmental MQt, LLC U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facility's Phone:9163510980 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, CAD980884183 <br /> HM and Packing Group(if any)) 10.Containers <br /> 11.Total 12.Unit <br /> ir X UN3249, Waste Residue Last Contined, No Type Quantity Wt.NOI, 13.Waste Codes <br /> a aMedicine, solid, toxic, n. o. s. I CF 00001 F' 311 '0011 <br /> w 6. I FSG II, ERG#151 (Warfarin}, <br /> w X UM28I04 Waste Toxic, liquids, organic, n. o. s, j <br /> (Barium, M—Cresol) , 6. 1, 1='G II, ERG#153 DM 00025 F <br /> ' 311 ID05 DO22 <br /> 3. <br /> D024 ; 129 058 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1 k�i i�89(Gen. St? r <br /> t-t <br /> 4 2� 7f+4'19(RX TOxic Liquids) s Determination Excludes Container Wt. ) CfV'I <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION; IIIereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,a d are classified, <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 pa <br /> I that the waste Exporter,I cerfify that tminimization statement identified ient n 40 FRnform to t262.2he 7(a)(if s of I amta large qched uantity generator)Acknowledgment <br /> (b Consent.fl am a packaged, <br /> Primary <br /> enertq/Offeror's P'nted/Typ d Name <br /> ( small quantity generator)is true. <br /> S •�dig �� Signatur <br /> 6.Intema ional Shipments Y Month Day Year <br /> H ❑Import to U.S. <br /> Z Transporter signature(for exports only): <br /> Export from U.S. Porto ent xit: <br /> Qf W 17.TransporterAcknowledgment of Receipt of Materials <br /> Date leavin U.S.: <br /> F- Transporter 1 Printed/Typed Name <br /> a Isidro Martinez <br /> Signatur _ <br /> QTransporter 2 Printed/Typed Name Month Day Year <br /> Signature 12 05 .;kt19 <br /> 18.Discrepancy Month Day Year <br /> 14 Discrepancy Indication Space <br /> ❑ Quantity <br /> ❑Type ❑Residue <br /> ❑Partial Rejection <br /> JFacility(or Generator) <br /> �- 18b.Alternate Facili ❑Full Rejection <br /> Manifest Reference Number: <br /> U <br /> LL Facility's Phone: U.S.EPA ID Number <br /> UJ18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyclingsystems) Month Day Year <br /> p 1. <br /> 3. <br /> ILAI 2 <br /> 20.Designated Facility Owner or 0 4. <br /> Printed/Typed Name Operator.Certification of receipt of hazardous materials covered by the manifest e <br /> as n Item a <br /> Sign ure <br /> EPA Form 8700-22(Rev.12-17) Previous editions are o olete. <br /> Month Day Year <br /> DESIGNATED FACILITY EPA's e-MANIFES . vcrIZ A <br />