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print or type.(Form designed for use on elite(12-pitch)typewriter.) 111111111111111 <br /> Form Approved.OMB No 2050-0039 <br /> 1.Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 4.Manifest ac in Number <br /> UNIFORM HAZARDOUS i #377Zr. <br /> =(31f <br /> ( $ 0 FLE <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Add ess Generator's Site e�rent ,ailing address) <br /> Victoria' s Secret 1144 'Victoria' s Secret#1144 <br /> 2094761963 4950 pacific Avenue, Space 425 49510 pacific Avenue <br /> Generators Phone: Stockton, CA 95207 6t oc t On, CA 95207 <br /> 6. ransporter 1 Company Name U,S.EPA ID Number <br /> 9tericycle Specialty Waste 60lutions Inc MNS@00110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address General Envuro-nmentalU.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancher Cordova, CA 9574* <br /> Facility's Phone: 91 6351 0980 A9888418 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt'Nol` <br /> 1. Non RRA hazardous waste, liquid (Soaps, 1 CF (D@M3 <br /> Lotions), <br /> cu <br /> a 2. <br /> tu <br /> .,_ <br /> 3. <br /> 's <br /> 4. <br /> a <br /> 14.Special Handling Instructions and Additional Informafion 1. 1 1 0902(9t at a Regulated Liquids) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the pr shipping frame,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 regulatiohs.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)J I am a small quantity generator)is tr-. , <br /> Month ay Year <br /> Generators rocs rinted ype ame 1gnature CL. r,e n i o f L i n i t e <br /> 1' 04 2017 <br /> .J 16.International Ship ents <br /> ❑Import to U.S. ❑Export from U.S. P rt of entry/exit: <br /> Trans iter signature for .............. <br /> exports only): Date leaving U.S.: Pl <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> � Transporter 1 PrintedlTyped Name Month Day ear ignature ', i�� ,�,. <br /> a Johnny Harper ! �,�����' t'k�ii ��„ ' <br /> 1 04 7 <br /> ZTransporter 2 Printed/Typed NameSignat a Mon ay ear <br /> 18.Discrepancy .'. <br /> M i <br /> Full Rejection <br /> 18a.Discrepancy Indication Space ppt ❑ <br /> ❑ Quantity ❑Type ❑Residue ,��'' <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPi <br /> i <br /> Q <br /> WLL Facili s Phone ( . (+',,r Month Day Year <br /> 18c.Signature of Alternate Facility(or Generato77 <br /> Q ,I <br /> 0 <br /> W 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) I i , <br /> 1 4, 07 <br /> °n <br /> 2. <br /> , r1"til�rl <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month <br /> Z5� <br /> ame Signature Day Year <br /> EPA For -22 ev.3-05) Previous editions are obsolete. � A� j AGILITY T0 Of8 BATE{3F RE(�t11RECl) <br /> Ifr, <br />