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i <br /> ase print ortype.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050 OOa9 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man est racking Numtier e <br /> WASTE MANIFEST CAL0003 X4264 1 8775172661 011385 12 1�e LC <br /> 5,Generators Name and Mailing Address 6enerator'5 Site Address(if different than mailing address) <br /> Walgreen #2680 Walgreen#2680 <br /> 2099412x16.4 15 W. Handing Wad, 15 W. Harding WsN, <br /> GeneratofsPhone: Stockton CA 135204-5716 'Stockton, CA 95204--5716 <br /> Transporter 1 Company Name U.S.EPA ID Number <br /> Stet-ic ycle 5 ecialt Waste 901uti0n, Iris 141\151211210110%,41 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Worldwide Recovery Systems CAR000175422 <br /> 8 Desgriated Forility Nameand SiteAddire,s Yuma Yes( LLC J,S.EPA toNumber <br /> 2730 E. lath Street <br /> 1'+.ttgc°a, A! 85:30Facim's Pncne: r1i;•BG428938 AZ RO00515924 <br /> 9a 9b,U.S.DOT aescrpt:on(induz.,ng Proper Weping Norie,Hazard Class ID Number, 10,Containers 11 Tota: 12.Urit 3,',Na3te Codes <br /> HM and Packing Group('any)) No. Type Quantity Wt.Nat, <br /> 1iVon RCRA haaardocls (wast`, z.011d tLDtt utntat 3 CF Ova lE Fr <br /> 'raduc:ts) <br /> 2Nan PC€2A hazardous waste, liquid (Water Based 1 OF 00107 P 331 <br /> Pruuu.c`i;5) . <br /> z <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1.6048(Stat t: Reg Solids) 2.6047(State Req Liquid) <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 labeiedlpecarded,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 Cons <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b) am small quantity generator)is true. <br /> Nene Ato s erors n e Typedame rgna ureVolay Year <br /> � � 1 091 28 201 <br /> 1 , nternational Shipments <br /> El Import to U.S. ❑Export fso .U.S- Port of entn�-exi <br /> ' <br /> rrens over signature'for exports only Date lea U <br /> i <br /> 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter;Printed/Typed Namenatur ort ay eer <br /> Anthony` Flack I 09 F?8 1 201 . <br /> Transporter 2 Printed/Typed Name nFar XtV MonthDay Year <br /> 18-Discrepancy <br /> 18a.Discrepancy indication Space t <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> t <br /> t <br /> i <br /> Faciti 's Phone: <br /> 18c.Signature of AEtemate Facility{or Generator) Month Day Vear <br /> r <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 1- 2. 3. 4 <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as in item 1 as <br /> Printed, ype N me ignattve Month ay Year <br /> A Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGNATED OACILIW40 DESTINATION STATE(IF REQUIRED) <br />