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Please print or",(Farm designed ftx use on elite(12-pitch)typewriter.) 4 � V��� Form Approved.OMB No.2059-0938 <br /> UNIF=HAZ=ARVWS1-G—fab"IDNumber 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Nummbeer <br /> WACALL 0039 073 €877 57?-266910002124-18 DAT <br /> 5.Care atOrs Name and Aiailing Address Generators Silo Addre s(if different than marring address} <br /> Dib LOTS STORES 115 LOTS 14457 <br /> 389 PHILLIP B MIN: VA FERARU 25 1 9. TRWY im_ <br /> Garterator'sPhone, COMM OH 1322o TMY CA 35336 <br /> 6.Transporter 1 Company Name U S-EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS !KC f?I9Sf)�OT1fJ32� <br /> 7-Transpo tar 2 Company Name U.S.EPA+D NNumbepr µ 7 <br /> V� "o-G,p I V f O , £-,- <br /> 8.Cesignated Focality Name and Re Address U.S.EM ID Number <br /> 21ST CORM ENvIRawgi -awkaW CF NEyff 4, LLC <br /> 2995 btlaeds Drive East <br /> Faaiity'sPhone: FEACR, HIf 91498 1715) 575-226D 1�V334BC1$95338 <br /> 9a. 9b.U.S.DDT Descippon(irtdudina Proper Shipping None.Hazard Gass,10 Number, 10-Containers 11_Total 12.Unit <br /> HM taad Pang Group('rP any)} - Tyf- Quantity 1VL Voi. #3-Waste Gages <br /> Cr <br /> 1. 4f1�i�59 3f95TE �S 2. AD4$9B1=1DG 17k P 331 DDD1 <br /> LLA <br /> z <br /> LU <br /> ] ' r <br /> ��y <br /> TT�1&MVWX WL111111111Z ill <br /> i <br /> 14,Saedat IiandfiOg Instructions and Add!Wnal In#otmatian <br /> (1) {_f �fi - � - EQ6{i263 lIt45{ 5 <br /> 15. MERATOR'SOFFEROR'S CERTIHCATION: I hereby dedars that the porttertl5 d this consignment are fully and amoral Vy described above by the proper sopping name,and are cfrtrAed,paclWed, <br /> marked and labaiodlplar�rded,and are in all respect9 in proper mMiUon torttvsport according to appfeable intemationel and national gavemmentEI raguiab¢ns.If export shipmeat and!am the Primary <br /> Exporter,10afty brat the contents of this consi rA*w t confirm to the arms of the attached FPAAdmowk)dgment of Consent <br /> I certlfy that thu waste minimizaton statement identified in CO CFR 262.27(a)(if I am a large quantity Pmralnr4 w( am a moll q eratp}is fi-re. <br /> Genorator910ffenors thin Name svatu Month Day Y.r <br /> _ <br /> Y <br /> � 1 fi-I aiiorta;Shipments <br /> [— €mpori to Ii.S. ❑Export tram U.S_ Pat of enftyr'eXA: <br /> z <br /> Traniportefs natura fnrex <br /> 9 { Crtly): Date Iuavrrlg U.S.: <br /> � 17.Trar"orVA6 nowedgmenl of Reraipf of Matenais <br /> R Transpartur 1 Printed Z'T <br /> me S gna[ure Month Day Year <br /> IL <br /> �t t <br /> z Transporter 2 PrirtedlTyped Narna Signature Morrh Day Year r <br /> 1a Deorepancy <br /> 18a.Disaepaney Indicafion Spate Quantity ❑Type ❑Residue ❑Partial Re, tion ❑Fult Rejection <br /> Marafesi Reference Number, <br /> or Cenerma U.S EPAID Number <br /> 18b.Alternate Faoldy( } <br /> a <br /> v <br /> ria Fadity'S Phone' Month Day Year <br /> W IBc.Signature ofA6emataPadlity(orGertarator) <br /> !;C- <br /> S2S2 <br /> 19,Hazardous Wasie RqW- Management Method Cpde6(i.a.,Codes fur hazardous waste treatment,disposal.and recyGing systems) <br /> UJ <br /> 20.Designated Facifty Owner Or Operator:Certification of racetpt Of h awdous mabKiels cater ad by the manifest except as noted in Item 18a <br /> Pd*dffyped Name Signature IY <br /> EFA Form 8700-22(Rev.3-05) Previouseditions are obsoiete. DESIGNA FACILITY TQ E TINATIOt+t STATE(1F REQUIRED) <br /> UIRED} <br />