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RECEIVED BY SJCEHD (EF) on 8/9/2019 <br /> !'lease print or type.(.Form designed for use on elite(12-pitch)fypeurile(.) ForrnIApproved.OMB No.2050-0039 <br /> l!NlFpRivi htAZARDOU5 t.Generalnr ID Number 2.Pagu f of 3.Fmsergency Response Phony 4.��Maan/iffest ra'c�1 in Num�j 1-y <br /> WASTE tAANIFEST CIALE 001-4910� � t S�( i 5 d?-- I?u LJ0 �1 �:� / Q 5 DAT <br /> 5-Genera o.rG Name and tdlalling Address Generato.'s Sile Address(if different than mailing address; <br /> t3& €.a.15 S1t1RB B16 t.fft5 $5451 <br /> 390 KILl_IP RD ATIW: IFIM FERRRU 1551 0. TRACY ILVD. <br /> GeneratofsP11or1e: COLON )5 N 43229 (6I4ma--mi Tfti1GY CN 55315 <br /> E.Transporter 1 Company Name U.S.EPAID Number <br /> STERICYCLL SPECIP11- Y WRSTE SOLUTTQNS INC ri#Ili0t7t111CIu:?b <br /> 7,T r 2 Company Name: <br /> f/r1 U.S.IrP ID—Number <br /> tis t <br /> 7Fz6b"PhOne: <br /> Name and Sita Address <br /> U.S-E Aln ONumrr <br /> 5 Drive East <br /> wy NY 54480 (175) 575-2750 IV�II?!3�3E369633$ <br /> ga 9b.U.S_DOTDescr'plion(incfuftq Proper Shipping Name,Hazard Class,ID Number, Io-C.ontainM. 11,Tota! <br /> i2.Unit <br /> _ <br /> and Eracl:ing Group(i1 any)) No. Type quantity Wi-lVOL ot_ 1n'Waste Codes <br /> 1 <br /> 0111958 99ST€ AEROSOLS 2.1 WHOMM) 3I RiIRI <br /> UA <br /> P. N0941, LMAI, Milie, <br /> 3 � r� 11119 <br /> r v <br /> d <br /> . . PGII iI5 <br /> 14.Special HandUng in 06 andAddilianal[nformalion <br /> (1) XKRGSOL5-63 - MUM AEROSOLS t21 ]MR11CIR-03 •- LR&(154) ACIDIC CORROSIVE LIC (3) IMWRMSIC-I#) - ERG(154) <br /> ASIC URifilSTWE LTW (4) N-FLM.N-13 _ ERLM70 FUMIU LIMILS <br /> 15. GENERATW31O TEROR'S GER11FIGATM: I hereby dewre final the contents of this consignrfont ase fully and accurately described above hytho proper shipping name,ani are cfassiQ 1.packaged, <br /> markod and labeledlplararded,and are fn ell respects in groper oanditson fortransPort according to applicehc inlernationaland national9M)rnmentai m9ufatrons.If expel shipme nl and f am the Primary <br /> [aporler,f cerlify that Me contents of this cons€gnmrmtowform to ft forms of the aUached EPAAclmouledgment of Consent. <br /> f cert fy lfia the waste nrin mzafion statement identified in 48 CFR 262.27(a)(if I am a 4rge pffenthy gereraler)or(b)(if I em a sma8 quantity generator)is Ince. <br /> Gc fofs t]ffero's Prinfed�If 4 � $g Month Day Year <br /> 14 <br /> r 16,inlemational Shiprrsewilisf <br /> r ❑Impost to U-S. Export tram U.S. Pori lA byiexit: <br /> Transporter signal;ire(for ezpuds only): Date leovinq U.S.: T� <br /> W47-7rare;gorier Acknvvtedgment of Rea'ipt of tyfalCfials <br /> T?arrsponor1PdirltolTypedName Signature Month flay Year <br /> 7'ransporier2 Printed d Name Signature NlonBt Day Y r <br /> ELt <br /> f- <br /> 18.Ciacrepancy <br /> 18a.Discrepancy indicalion Space Ll Quantity ((�,� —lt � <br /> L-3 Type D Residus Partral Rejecfion Dull <br /> I Full Rejection <br /> Manifest Reference Number: <br /> 18b Attemala Facilely(or Generator; U.S.EPA 10 Number <br /> Faeflityrs Phone: <br /> in 1&c.SignalureofAllernateFadfity(orGarreralor) Monlh Day Year <br /> 19.Hazardous wasle Report Management Method Codes#e-,cndes for hazardous wasle treatment,disposal,and recycling systerns} <br /> 1 <br /> Uj <br /> 420,Des <br /> pated <br /> 7()wnw <br /> =Operaqw- <br /> Z- 3, 4. <br /> lily or CeMIcabIll of receipt of hazardous materials covared by the main€est except as noted in Ilem 18a <br /> Ptinterill'yped Name <br /> Signature Moglh Day Yaar <br /> EPA Form 8700-22(Rev.3.05) Previous ecliftins are obsotele. <br /> DESIGNATED FACILITYTO DESTINATION STATE ff REQUIRED) <br />