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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t.Generator IO Number2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number 1 17 <br /> WASTE MANIFEST CAL000426099 1 8775772669 012495969 FL-r-- <br /> 5,Generator's Name and Mailing Address Generat&s 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 19 Number <br /> Stericycle Specialty Waste Solutions Inc MNS0001i0924 <br /> 7 Transporter 2 Company Name U.S.EPA 10 Number <br /> Worldwide Recovery Systems CAR10100175422 <br /> 8.Designated Facility Name and Site Address Yuma Yes, LLC U.S.EPA 10 Numner <br /> 2730 E. 13th Street <br /> Yuma, AZ 85365 <br /> Facility's Phone: 9286428938 AZR000515924 <br /> ga 9b.ij,S DOT UescwtiQn(including Proper Shipping Name,Hazard Class,ID Number, V: ccritainers 11.Total 12 Unit 13,kVasie codes <br /> H?,j and Packing Group(;!!any)) No. Type Quart Vy vvblvol, <br /> on RGA hazardous waste, solid (Soaps, I CF 00008 P 331 <br /> 0 Lotions), <br /> Z 2-Non RCRA hazardous waste, liquid (Soaps, I CF 00031 P 331 <br /> UJI <br /> Lot ions), <br /> 4. <br /> Special Handling fristruclinnsaid Additional Information 1. 110903(State Regulated Solids) 2. 110902(State Regulated <br /> Liquids) <br /> LOD <br /> 15, GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the conterils of this consignment are fully and accurately described above by the proper sh pping name,and are classified.packaged, <br /> marked and labeWplacarded,and are in all respects in proper conditon for transport according to applicable internationaland national governmental reguWlons.If export shipment and I am the Primary <br /> Exporter,I carl[Ify,that the contents of this consignment conform to the terms of the attached EPAAcknow"ment of Consent, <br /> I ceffity that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(ifl am a small quantIly geneiratorl,is true <br /> " <br /> Gererator'sLofferor's Printpdrryped Name Signature SRL;L e on be halfof Li m 1 Morilh Day Year <br /> --!)I e-5,),:; �-6( Lie 121 011201111 <br /> 16.International Shipments <br /> 111mrrittoU.S. E1Expert from U.S. Pod of entrylexiL ------- <br /> Transporter&9nalure{tor exports only). Date;eav ng U,S.� <br /> 17,Transporter Acknowedgmerl of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> Jesus A Marquez Ortega 1 121 011 211171111 <br /> Z <br /> tans iter 22 Printedinry ad Name Signature Month Day Year <br /> —5screpancy <br /> 18a.Discrepancy Indication Space ❑ Quantity 11 Type El Residue E]Partiq'Rejection Ful Re,eclicr <br /> Manifest Reference Number: <br /> 18b.Alternate Facifilly(or Generator) U.S.EPA ID Number <br /> Facility,Phone: <br /> Lo 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2. 3. 4. <br /> 4U U I I ih(-O I — <br /> 20.Design"FadAy Owner or Operator:Certification of receipt of hazardous materials covered by the manifest+ps noted in item 18a <br /> Prinlecill'Typed Name Month Day Year <br /> ci�-Vi I In —1 (11-n), l I 1`4471A 10 <br /> EPA Form 8700-22(Rev.12117) Previous editions are obsolete. V-SI-qOftgFACILITY TO EPA's e-MANIFEST SYSTEM <br />