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Please print o:+type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 2 1-866,547-2857 1 011058132 F L E 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address; Doctors Hospital Manteca Doctors Hospital Manteca 1205 E North St 1205 F North St Manteca, CA 95336 Manteca, CA 95 336 Generator's Phone: 559-304-4093 6.Transporter 1 Company Name U.S.EPA ID Number Healthwise Services CAL000370179 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U S.EPA ID Number Vail ES Technical Solutions LLC 1125 Hensley St GA70OW14079 Richmond, CA 94801 Facility's Phone: 800-243-23& ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12 Unit HM and Packing Group(if any)) No T—YPd Quantity Wt 1Vol 13.Waste Codes W 1 UNI 950, Aerosols, poison, 2.2 (6.1 311 i Q X ' DF 7 P L I LJ LLIX 2 UN2811, Waste Toxic solids, organic, n.o.s. (M-CRESOL}, 6.1 I ^F r J D011 D024 311 ll -1 3.UN2811, Waste Toxic solids, organic, n.o.s. (NICOTINE, P0011 P075 311 X WARFARIN), 6.1 , II P - -_- - 4 UNI 993, Waste Flammable liquids, n.o.s. (ALCOHOL, DOW F003 214 X XYLENE, PETROLEUM DISTILLATESI, 3 , ll LJ P 14 Special Handling Instructions and Additional Information Document: D235W6 1)993215 ERG#126 6 x SJ 3)%,3212 ERG#1154 2)993209 ERIl(x\s) 4) 1 t' 0q ERG#128 Cx 5) 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, 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 Exporter.I certify,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement idertified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators!Offeror's Printed/Typed Name Signa Month Day Ye5r 1 4 «ce h n I AA 112 1 -7 1 1 7 16.International Shipments ❑Import to U Export ry F— ❑Ex rt from U.S. Port of ent lexit: Z Transporter signature for exports only): Date leaving U.S.: W 17 Transporter Acknowledgment of Receipt of Materials Tra rtjr�ipt intedlTyme ignature ont ay ear N1(2- 1 z Transporter 2 PrintecIrTyped Name J Signature Month Day r 18.Discrepancy 18a.Discrepancy Indication Space ty ❑Type ❑ ❑ j ElFullRejection El Quantity T e Residue Partial Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U Q u Facility's Phone: LAO 18c.Signature of Alternate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(i e,.codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 111 ►'� IH I H IHS 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name Signature Month Day Year t1n M r Jii,%i I -a)&� 1 1211 EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)