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r Please rintor Iu11ti�����INIII�N11lin�u� <br /> p type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 72. age 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST I CAL000426099 1 8775772669 012495968 F E <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Victoria' s Secret 1144 Victoria' s Secret#1144 <br /> 2094761963 4950 Pacific Avenue, Space 425 4950 Pacific Avenue <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 MNSOOOI10924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site dress snt ury LPIN, LLU U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone: 7755752760 N V D980895338 <br /> ga. 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)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. , Waste Aerosols, [flammable, (each not 1 CF 00002 P 33 D00i <br /> W exceeding 1 L capacity)] 2. 1, ERG#126 <br /> w <br /> W 2. , Waste Flammable liquids, n. o. s. (Ethyl 1 CF 00021 P 33 D001 IJ002 <br /> Alcohol, Acetone), 3, PG II, ERG#128 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 110904(Aerosols, Flammable) 2. 110905(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 EPA Acknowledgment 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 true. <br /> Genera erors Printed/Typed Name Signature SRC rep on behalf of L i m i t e Month Day Year <br /> e a-S 1 121 01 201 <br /> 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> QC LU <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a Jesus A Marquez Ortega 12 01 201 <br /> z Transporter 2 Print d/Typed Name Signature Mo th Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. AIL Y 2. H 3. 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 /> Printed Hyped Name Sig ureMonth Day Year <br /> a1QGa= 0 W�= I 1 19 1 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 8700-22_12v3 08293378 S41067702 041261175 M PD120118 SDI20118 <br />