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Please print ortype.(Form designed for use onelite(12-pitch) pewrHer. <br /> ty ) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000427616 ��� 010076841 FLE <br /> l 8775 r,266'3 <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Path 6, Bodv Work_ 1510 Hath 8• Body Works#1511 <br /> 2094-129339 4951,1 PACIFIC AVE, WEBERSTOWN MALL/ SPACE 4950 PACIFIC AVE <br /> Generators Phone: S T OCKTON ?:A 95207 1S 1 QCNTQN. CA 95_N7 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 5tericycle Specialty Waste Solutions Inc i�1VSVtr<t01 '09,'='4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> ueneral Environmental No` - 1 L U.S.EPA ID Number <br /> 11855 White -•ack Road <br /> Facility'sPhone:glb3s(alira Rancho Cordova, CA 95742 Nd-d�ir-Kfif} <br /> 9a, 9b.U.S.DOT Descriplion(including Proper Shipping Name,Hazard Class,ID Number, 1D.Conlainers y <br /> HM and Packing Group(if any)) 11.Total 12.Unil v 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> i. <br /> o Mon RCRA hazardous waste, solid (Soaps, 1 Cr 00024 P 331 <br /> Lotions), <br /> 11J <br /> 2. <br /> Non RCRA hazardous waste, liquid (Soaps, 1 CF 0,00377 P 331 <br /> Lotions), <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Liquids) i. 110903(State Regulated Solids) 2. i.1090`(St ate Regulated <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of tNs consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> 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 <br /> Exporter,l certify that the contents of this consignment conform to ft terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if I am a small quantity generator)is We. <br /> Genera Offerors Printed/Typed Name Signal e <br /> Month ay ear <br /> behalf of Limite <br /> .� 16.fntematiShipments +_ i <br /> ❑Import to U.S. El Export from U.S. Port of entrylexil <br /> Transportersi nature for exportsonl Date leavinq U.S.: <br /> JX 17 .TranspofterArknowledgment of Receipt of Materials <br /> Transporter 1 Printed/iyped Name To -&7--- <br /> O ort ay ear <br /> a Kristooher Almanza I + - <br /> Z Transporter 2 Fnnted/fyped Name <br /> Si9gnature Mon� Day II ear <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> IZ 18b.Altemate Facility(or Generator) Man fest Reference Number. <br /> :3 U.S.EPA ID Number <br /> U <br /> Q <br /> LL Facili s Pfrone: <br /> 182.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1 2. 3. 4. <br /> 20.Design ed Facility Owner o Operator.Cerlificadon of receipt of dous materials covered by the manifest cept as not i em 18a <br /> Printed ped Name % Sign <br /> Month Day Year <br /> EPA For 00 2(Rev.3.05) Previous editions are obsolete. <br /> D MATED FACILITY TO TINATION STATE(IF REQUIRED) <br />