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Please print <br /> .or type.(Form designed for use on elite(12-pitch)typewriter. 1111 <br /> �I � � \ <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Trackln, <br /> WASTE MANIFEST CAL00042761G 0�o]n� ��'I �� <br /> 5.Generator's Name and Mailing Address 1 877.,77�GG9 01 ►I( <br /> Generator s Site Address(f ditteic— <br /> fenl Ihan mailing address) <br /> Hath R Body Works 1510 Bath & Body Works#1 ' <br /> 2094729339 4950 PACIFIC AVE, WEBERSTOWW MflLL1 SPACE 4950 PACIFIC AVE <br /> Generelor'sPhone: STOCKTDtd, CR 9507 <br /> Company Name STOCK70l, CA 95201 <br /> 6.Transporter 1 <br /> U.S.EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc <br /> 7.Transporter 2 Company Name 1�1N500Q11109c4 <br /> U.S.EPA ID Number <br /> B.Designated FacilityNameandsite AddressGenel al Environmental rgt, LLC <br /> U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Facilis Phone: Rancho Cordova, CA 95742 <br /> l� i .� � <br /> ga. 9b.U.S.DOT Description(ncluding Proper Shipping Name,Hazard Class,to Number, <br /> t0.Containers <br /> HM and Packing Group(f any)) t0uanli7�/ WLNOI, <br /> 13.Waste Codes\ <br /> No. Type W Non RCRA hazardous waste, liquid (Soo sLotions), P 1 9 DF X1148 331 <br /> Qi -w <br /> --H <br /> z 2. <br /> w <br /> 3. <br /> p14.Spe:dcial Handling Instructions and Additional Informat on <br /> 1. 1109C,i2(State Regulated Liquids) <br /> 15. GEN ERATOR'SfOFFEROR'S CERTIFICATION:1 hereby declare Ihal the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfpiacarded,and are in all respects in proper condition for transport according to applicable inlemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that Phe contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> IIn certify that the waste minimization statement Identified in 40 CFR 262.27(a)(f I am a largo quantity generator or of I am a small quantity <br /> Generators/0fterorsP11 :Ki/TypedName ) �) 9 lygenerator)istrue. <br /> igna ure <br /> C e p o e h l f f t. Month ay ear <br /> 16. lemational Shipments O <br /> F- ❑Import to U.S. <br /> z T ns iter si nature for ex rts onl): Export from U.S. Port of entry/exit: <br /> W 1 .TransporterAck mo.Modgment of Receipt of Materials Date leavin U.S.: <br /> Transporter 1 Prinledflyped Name <br /> p gnature <br /> IL I on ay ear <br /> W <br /> I r I <br /> Transporter 2 r11111LWtYPaU Name I` <br /> Signature M <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Orranhty ❑Type Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> M.Memate Fac"lly(or Generator) Manifest Reference Number. <br /> J U.S:EPA ID Number <br /> V <br /> LL Facrli s Phone: <br /> F181.Signature ofMemate Fact ily(or Generator) <br /> z Month Day Year <br /> 6, 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment d sposal,and recyrng systems) <br /> LU 1 <br /> C � 2. 3. <br /> 4. <br /> 20.Designated F ity er Of Operator.Certification of receipt of haza aledals covered by the manifest exceas noted k1 Ile a <br /> Printed/Type me <br /> Signatu <br /> Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edition are obsolete. Q <br /> DE NATED ILITY TO DES ION STATE 1IF RFnt rlD m <br />