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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> WW � <br /> UNIFORM HAZARDOUS 1.Generator iD Number Form Approved,OMB No.2050-003; <br /> WASTE MANIFEST CAL00@427616 2.Page 1 of J.Emergency Response phone 4.Manifest Tracking Number <br /> n� 1 8775772669 008629418 <br /> 5.Generator s Name and Mailing Address F L E <br /> Bath 8- B o d v Works 1510 Generator's Site Address(if different than mailing address) <br /> 2094729339 4950 PACIFIC AVE Dath u Bode! Wor-ks111510 <br /> WEBERSTOWN MALL/ SPACE 4950 PACIFIC AVE <br /> Generator's Phone: STOCKTON, CA 95207 <br /> ransporter Company ami STOCKTON, CA 9507 <br /> Stericycle Specialty Waste Solutions Inc U.S.EPA1DNumber <br /> 7.Transporter 2 Company Name MNS000110924 <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> ra ..vlronleen a g , <br /> 11855 White Rock Road U.S.EPA 1D Number <br /> Facility's Phone: 9163510980 Rancho Cordova, CA 95742 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, CAD980884183 <br /> HM and Packing Group(if any)) Pfx 9 10.Containers <br /> 11.Total 12.Unit <br /> Iz <br /> 1 Non RCRA hazardous UJ waste, liquid (Soaps, 1No Type Quantity Wtvoi 13.Waste Codes Lotions), DF 00116 P 331 <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling In--0-and Additional Information <br /> 1. 110902(State Regulated Liquids) <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above the <br /> marked and certify <br /> that <br /> the rded,conte and are in all respects in proper condition for transport according to applicable international and national govemmenfal regulations-If export shipment <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. proper shipping name,and are classified,he packaged, <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity enerator or(b)(N I am a small quantity p and I am the Primary <br /> e eror's Printed/Typed Name q ty generator)is true. <br /> igna ure <br /> t ` A r rep ehalf o Limite " ay ear <br /> —J 16.Inter tional Shipments <br /> I-- 11 <br /> Z Trans orter si nature for ex orfs onl Import to U.S. ❑Export from U.S. pod 10 201 <br /> ry/exit_ <br /> W17.TransporterAcknowledgment of Receipt of Materials Date leavin U.S.: <br /> Transporter 1 Pr ntvu,1 yped Name <br /> O <br /> On gnature <br /> Phi M r onth ay ear <br /> QTransporter 2 Printed(Typed Name I <br /> ignature <br /> on Day <br /> 18.Discrepancy ea <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity <br /> EJ Type <br /> ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> I-- 18b.Alternate Facility(or Gene ator) Manifest Reference Number: <br /> J_ <br /> V U.S.EPA ID Number <br /> Q <br /> LL- Facilit's Phone: <br /> F18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> 0 Month Day Year <br /> ELU 5 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and res clic. <br /> � 1I Iq I 2 Y 9 systems) <br /> 3 <br /> 4 <br /> 20 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Pdrited/Typed Name <br /> [PA,Form 8722 I Month Day Year <br /> ev.3-05) Previous editions are obsolete. 1 y <br /> JDE6iGNA F0 FACILITY r 1 t I <br /> . To S TAT F"IF AFni lin— <br />