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Please print or e. Form designed for use on elite(12-pitch)typewriter.) I Form Approved.OMB No.2050-0039 <br /> P YP ( 9 { P )tYP ) PP <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000427614 1 8775772669 011413284 F L E <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Bath & Body Works 65 Bath b Body Works#65 <br /> 2099524396 5308 PACIFIC AVE, SHERWOOD MALL/ SPACE 6 5308 PACIFIC AVE <br /> Generators Phone: STOCKTON, CA 95207 STOCKTON, CA 95207 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNBIdIdAiA� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> f <br /> 8.Designated Facility Name ariM Site Address :11st en ury , ILLU U. .EPA ID 95mber <br /> 2095 Newlands Dr. East <br /> Fernley, NY 89488 <br /> Facility's Phone:7755752760 KVD980895338 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 1 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> Waste AerosoLe, Lflawmable, (each no ( <br /> o exceeding 1 L capacity)] 2. 1, ERG#126 <br /> Z X UN19911, Waste Flaswable liquids, n,o.s. (Ethyl 1 CF OW12 P 331 D"I ,UM <br /> LLJ <br /> Alcohol, Acetone), 3, PG ]I, ER6#12H <br /> 3. <br /> I � <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information 1.110904 l Aer uuo 8, aMna e) 1 5(Flammable Liquids) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this 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,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is[rue. <br /> Generator's/Offeror's Printed/T ped Name igna ure YEer on @ a 2 w e on ay ear <br /> �r Yi t� 05 31 201 <br /> —J 1444eriational Shipments <br /> [— Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed NameignatureMonth ay Year <br /> C) Daniel Lege I 051 31 170if J,-A.4.4 <br /> Z Transporter 2 Printed/Typed Name 9ignaWeV Month Uay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity El Type Residue ❑Partial Rejection ❑Full Rejection <br /> ❑ <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> �+- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e..,-co des for hazardous waste treatment,disposal,and recycling systems) <br /> LLI1. 4. <br /> 2D.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the maME <br /> Printed/Typed Name1 () Doth Y <br /> 4 ou i <br /> 2 <br /> 16 <br /> EPA Form 8700-22(Rev.3-05) Previ us editions are obsolete. ED FACILITY T DES (NATION STATE(IF REQUIRED, <br /> 8700-22 12V3 G629K-17714 S41I M7H.1 d, 11411:21101#, 11 # `+:l l)Ft ?i>1+7tia 1 1 A <br />