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Please print or type. Form Approved.OMB No.2050-0039 TUNIFORM HAZARDOUS 1.Generator ID Number - 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAR000220M 1 408-363-31578019412919 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) CDCR-CALIFORNIA HEALTH CARE FACILITY 7707 S AUSTIN RD. STOCKTON,CA 95215 Generator's Phone209-467-7904 6.Transporter 1 Company Name U.S.EPA ID Number ALL CLEAN HAZARDOUS WASTE REMOVAL INC. CAD9824923CA 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address CLEAN HARBORS ARAGONITE,LLC U.S.EPA ID Number 11600 NORTH APTUS ROAD UTD981552177 GRANTSVILLE,UT 84029 Facility's Phone:435-884-8100 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. }( 1. UN 1851,WASTE MEDICINE,LIQUID,TOXIC,N.O.S.,(WARFARIN, 311 P001 P075 o EPINEPHRINE),6.1,PG II ri000 P158 P204 UO10 z 4{ 2. UN3249,WASTE MEDICINE,SOLID,TOXIC,N.O.S.,(WARFARIN, 311 P001 P075 LU EPINEPHRINE),6.1,PG II Y 8188 P204 0010 3. 4. 14.S ecial Handlin.g Instructions and Additional Information �)CH1a02505 1Di-los' (RCRAPharmaceuticals Tovdc-LIQ) GEN#CD3002 PO#A14019 2)CH18025002A (RCRA Pharmaceuticals Tam-SOL) II'f� ' 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, 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 EPAAcknowledgment of Consent. 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 quantity generator)is true. Generators/Off ror's PrintedffypedName Signature, Month Day Year -j 116.International Shipments I- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date le 'ng U.S.: 17.Transporter Acknowledgment of Receipt of Materials 12 TransporterPnnted/Typed Naro Signature Month Day Year O 1r t a Z Transporter 2 Printed(fyped Name Signature Month Day Year t- 18.Discrepancy 18a.Disc. Elrepancy Indication Space Quantity ❑Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 14. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM