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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) I
<br /> Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone Manifest Tracking Number
<br /> WASTE MANIFEST CALO@0427614 1 877577266914.
<br /> 010685568 F L E
<br /> 5.Generator s Name and Mailing Address Generatofs Site Address(if different than mailing address)
<br /> a Bath & Body Works, 65 Bath &. Body.Works#65
<br /> ' `r :2@9954395 • 5306 PACIFIC..AVE, ..S}{ERWOCID .MALL/ SPACE 6 530.8.;PRCIF.IC AVE
<br /> :y..� STOCKTON C
<br /> Generators Phone: ! A 95207
<br /> Transporter r t Company Name STOCKTON, CA 95207
<br /> U.S.EPA ID Number
<br /> Stericycle Specialty Waste Solutions Inc MNS000110924
<br /> 7,Transporter 2 Company Name
<br /> U.S.EPA ID Number
<br /> 8.Designated Facility Name,and Site Addres!;
<br /> ! U.S.EPA ID Number
<br /> ob
<br /> 2° r 4 C. CAD 83b�-m3'7
<br /> s+S C R`�03Dr w o...�cs w�c1� a Jt-v
<br /> Facility's Phone:
<br /> 9a I 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit
<br /> HM and Packing Group(if any))
<br /> 13.Waste Codes
<br /> No. Type Quantity Wl.Nol.
<br /> o -X. . 1993,.. Waste :Flammable 1 iquids, n.o.s. (Ethy.l., 1. CF . . @@@@2 P=. . .331 D0@1 U002-11-
<br /> 0 Alcohol, Acetone), 3, PG II, ERG#128 _
<br /> : w
<br /> 4- Aerosols,.. Eflammable, (each-not,: 4.
<br /> CF@00@1 P 331 D@@1
<br /> exceeding 1 L capacity)] 2. 1, ERG#126
<br /> Ao.n.,RCRA_hazardous,waste. liquid :. (Soaps,•, ,...i.,„ CF.: , . @@1 17. P,.. 331
<br /> Lotions),
<br /> Non.: .hazardous:.waste.,:•. solid-(Soaps, 1..,. ..,; CF:: @@@08 o- .-P,.. .._331
<br /> Lotions),
<br /> 14.3pedalHandlrglnstnx4totwand AdddronallnformaUpn i. 1109@5(Fla�fsable,, Li.
<br /> ggid,s•1, 2.911@904.(Ae.ros0.ls, flammable-1i. ',.:,3i:-:
<br /> (ltd e.Ae UTAtred:K4< quids) 4.1110963(State Regulated Solids)
<br /> 15. GENERATOR'S/OFFEROR'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 aging to applicable international and national governmental regulations.ff export shipment and I am the Primary
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br /> 1 certify that the waste minimi7a8on 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 true.
<br /> Generators 8eror's Prined yped NameSignature
<br /> c+a c rmonth Day Year
<br /> ..a 18.Intemational Shipments
<br /> Z ❑import to U.S. ❑Export from U.S. Portof errtrylexif:
<br /> Tr er signature for exports only): Date leavin U.S.:
<br /> W 17.Tran
<br /> sporterAclurowledgment of Receipt of Materials
<br /> Ifarwponer 1 Pdnted/fyped Name
<br /> O Signature Month ay ear
<br /> Z Transporter 2 Print dd
<br /> .y
<br /> 0i M Ut Day Year
<br /> 18.Discrepancy
<br /> a
<br /> 18a.Discrepancy Indication Space
<br /> ❑ Quantity ❑Type ❑Residue
<br /> ❑Partial Rejection ❑Full Rejection
<br /> 186:Alternate Faced Man'rfest Reference Number:
<br /> ty(or Generator) U.S.EPA ID Number
<br /> V
<br /> F • s Phone:
<br /> +I t8c Signature of Altemate Facility(or Generator)
<br /> Month Day Year
<br /> 19:,Hara(doUs Waste Repod Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1
<br /> �s 1 -------------------
<br /> y 2. 4
<br /> » 3.
<br /> 4.
<br /> �si�d FacBity Owner or
<br /> operator:Certification of receipt of hazardous materials covered by ifie manifest except as rested in Item 18a
<br /> S'gnature
<br /> Day
<br /> ... ��
<br /> ,a
<br /> C;
<br /> f r 2 (ReV.3 05) Previous editions are obsolete.
<br /> DESIGNATED FACILITY TO DESTINATION STATE(KR�_ `
<br />
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