Laserfiche WebLink
.e pnnt or type. (Form des <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />Mind <br />CAR001212623$3 <br />I� LGeneratoes <br />NmaadMailinAddrssCVS(SIS) #160238333494 2800 Naglee Rd, Suite B <br />Phone: ___.. Tracy, CA 95304 <br />2. Page 1 of 3. Emergency Response I <br />1 8009246804 <br />Stericycie Specialty Waste Solutions Inc <br />TID 49V tJama <br />__..__.,_„��,�„ ueneral Environlaental Mgt, <br />11855 White Rock Road <br />Rancho Cordova, CA 95742 <br />Facility'sPhone: 91635109$@ <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />X 1. UN3249, Waste Residue Last Contained, <br />Medicine, solid, toxic, n. o. s. (Warfarin), <br />,L, 6.1 PG II ERG#151 <br />X 2' UN28117 Waste Toxic solids, organic, n. o. s. <br />I (Chromium, Selenium), 6, 17 PG 1 11 ERG#154 <br />Form Approved. OMB No. 2050.0 <br />08597861 <br />CVS (SIS)#16223 <br />28@@ Naglee Rd, Suite B <br />Tracy, CA 95304 <br />4 <br />MNS@@011@92 <br />LHu98@884183 <br />10. Containers 11. Total 12, Unit <br />No. Type Quantity Wt.Nol. 13.Waste Codes <br />1 CF 00901 P 311 P@01 <br />1 ICF @0002 P 311 D0@7 D01@ <br />---------•-��.+.+�uwaimremtau0n 1. 1@1079 (Residue weight does not exceed 0.0436 lbs) CNT:11 2. <br />10@196 (RX Tnxic Solids ) <br />GE ked and RBIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Ib s consignment are fully and accurately described above b <br />marked and lr* that <br />the onceded, and are in all respects in proper condition for transport according to applicable international and national govemmentat regulations. If e <br />Exporter, i certify that the contorts of this consignment conform to the tomes of the attached EPAAckriowled Y � Primer �PPin9 name, and are classified, packaged, <br />I certify that the waste minimization statement Identified in 40 CFR the terms <br />(If I e a a la gment of Consent >� shliormt and I am the Primary <br />rrat e s n large quantity generat quantity generator) Is true. <br />�,, ` h. a erne if 1 am a small uanti <br />YYI iL%w rl �.,W*AJ� al re �1 <br />Elimport <br />to U.S. <br />17.7mnsporterAcknavAedgmenl of <br />Receipt of Materials <br />Phil Marciel <br />18. Discrepancy <br />18a. Disaepancy Indication Space <br />❑ Quantity <br />Generator) <br />19. Hazardous Waste Report Management Method Codes <br />20, Designate F 'lity Ovrner o Upemtor. CerOficatlon of <br />Print ypedName '�("/ <br />PA Form 8700.22 ( ev. 3-05) P�vi editions are ob <br />A7AA_47 1+}„� rI onirrarI <br />Export from U.S. <br />LJ►i <br />codes for hazarbus waste treatment, disposal, and <br />Port ofentry/exit: <br />❑Residue <br />of haiardous materials covered by the manifest except as rated in Item 18a <br />Signature <br />DESIGNA' <br />QPartial Rejectlon <br />U.S. EPA ID <br />02 071201 <br />02� 07201 <br />❑Full Rejection <br />IZ�2.o�i7� <br />FACILITY TO DESTINATION STATE (IF REQUIRED) <br />