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r. <br /> Please print or type. ' Form Approved.OMB No.2050-0039 <br /> UNIFOI2�A HdlZAR®OUS 1•Gen t r umb ET2� <br /> age 1 of 3. ergenV Res onse Phone 4.Mantfest Tracking Number <br /> WAST MPNIFEST 5U U ) <br /> 5.Generator's Name and Mailing Addres .(tAN s&4 Generator's SiteAddress(if different than mailing address) <br /> PA5.BOX 622t;20 ���4 ��r{ <br /> '�OCKTO ,cA 95206 r I <br /> 209-466-892" �� t ,t � �=�•�O�s <br /> Generator's'Phone: <br /> 6.Transporter 1 Company Name A ERIC A ��e�''' 'tri �tft i t U.S.EPA ID Number,-A "00272 V <br /> 7,Transporter 2 Company Name STERICYCLE SPEGIALT,"WA45VE-SOLUTIONS, NC U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address2 i ST CENTURY FNVlR0 PV1UFFAf MMMT F fyErVAPP ILC- U.S.EPA ID Number D _f <br /> 0 DJNEWILA 7 p t:8 <br /> ,mss <br /> FEFk�ILEY,IV 89408 <br /> Facility's Phone: <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.lvol. <br /> a ' <br /> 1• RO,P4A3077,HAZARDOUS, gA 'E-3 t.ID,N r. ., ;P itt, 1 L*1 1:.0 P t !I <br /> Y <br /> ® <br /> Z 2. z <br /> 6LI <br /> 0 <br /> a <br /> 3. <br /> j <br /> � I <br /> 4 <br /> i <br /> 3 <br /> 14.S ecial Handlin Instructions and Additional Information <br /> 1 E 597 02 ABSORBED` IV METALS ERGftl7l <br /> EMERGENCY CONTACT:T14OWS JAN <br /> E <br /> . x A <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately describe bo e-b the p oper_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 Conse . <br /> I certify that the waste minimizati statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I a small quantity generator)is true. <br /> Generators/Offerors ri t ped NameSignator Month Day Year <br /> r <br /> _.r 1611=t10Import to U.S. ❑Export from U.S. Port ofentry/exit: <br /> Tranature(for exports only): Date leaving U.S.: <br /> rX 17.Transporter Acknowledgment of Receipt of Materials <br /> LLITransporter 1 " d p a ` _ Signtwrt� -fs Month Day Yr <br /> Aa. <br /> ZTranspper7idiTypedName Signatures ont ay Ye'`af <br /> 18.Discrepancy �..f 4 '+ <br /> 18a.Discrepancy Indica on Space <br /> El r <br /> ❑ Quantity ❑Type' Residue Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) g U PAS mbA G3•,.�4 r <br /> E5 0,5 ThIr ' <br /> ut Facility's Phone: f O?I griv;vj a :�l ,: - :.•= <br /> w 18c.Signature of Alternate Facility(or Generator) this Month - ay Year <br /> a 4s" <br /> jc <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI 1. # 2. <br /> FDenated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> yped Name Signature —4_'" Month._1 Da Year <br /> n <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. <br /> DESIGNATED FACU` T GENERATOR <br />