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COMPLIANCE INFO_2019
Environmental Health - Public
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2200 - Hazardous Waste Program
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PR0541027
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COMPLIANCE INFO_2019
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Entry Properties
Last modified
1/6/2022 2:42:35 PM
Creation date
1/6/2022 2:17:53 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2200 - Hazardous Waste Program
File Section
COMPLIANCE INFO
FileName_PostFix
2019
RECORD_ID
PR0541027
PE
2247
FACILITY_ID
FA0023489
FACILITY_NAME
CVS PHARMACY #16223
STREET_NUMBER
2800
STREET_NAME
NAGLEE
STREET_TYPE
RD
City
Tracy
Zip
95304
CURRENT_STATUS
01
SITE_LOCATION
2800 NAGLEE RD STE B
QC Status
Approved
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SJGOV\kblackwell
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EHD - Public
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.�_ <br />,i 1. I <br />i i 1 I �.� ; I I <br />�'I � II I. ,� � tl , I <br />.ii JI' h.�.i:.:f �. II '�w :�• � :d • � 1 111 <br />Please <br />ff <br />anKeatTrecking Number <br />e <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />8009246804 <br />0 0 8 6 2 9 0 3 0 F L E <br />WASTE MANIFEST CA 8000262303 1 <br />5. nerator's Name and Mailing Address Generetol's Site Address (if ddferent than mailing address) <br />' <br />r <br />,i 1. I <br />i i 1 I �.� ; I I <br />�'I � II I. ,� � tl , I <br />.ii JI' h.�.i:.:f �. II '�w :�• � :d • � 1 111 <br />Please <br />pant or type. (rorrn aesignea ror use on sure t Ic-pncnl kypewlllal.r -• • - •• • •• •- - --- - - - <br />2. Page 1 of 3. Emergency Response Phone <br />anKeatTrecking Number <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />8009246804 <br />0 0 8 6 2 9 0 3 0 F L E <br />WASTE MANIFEST CA 8000262303 1 <br />5. nerator's Name and Mailing Address Generetol's Site Address (if ddferent than mailing address) <br />CVS tSIS) #16223 CVS ISIS)#16823 <br />2098333494 0800 Naglee Rd, Suite B 2800 <br />Naglee Rd, Suite H <br />Tracy, GA 95304 Tracy, CA 95304 <br />Generetor's Phone: <br />U.S. EPA ID Number <br />. ransporter ompany ame <br />Stericycle Specialty Waste Solutions Inc <br />MNS000110924 <br />7. Transporter 2 Company Name • <br />U.S. EPA ID Number <br />�� � �Y\ <br />8. Deslgnet Fedldy Name and Site A dress S e n Ur y , <br />U.S. EPA ID Number <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />7755752760 <br />NUD980895338 <br />Fadi' s Phone: <br />9a 9b. U.S. DOT Description (Induding Proper Shipping Name, Nazard Class, ID Number, 10. Containers <br />11. Total 12. Unit t 3. Waste Codes <br />HM andPaddngGroup(Oany)) No. Type <br />Quantity WtNoi. <br />X <br />1' UN2811, Waste Toxic solids, organic, n. o. s. <br />i <br />CF <br />00003 <br />P <br />311 <br />D007 <br />A010 <br />� <br />(Chromium, Selenium), 6. 1, PG II, ERG#154 <br />Fo <br />X <br />2�UN3249, Waste Residue Last Contained, <br />1 <br />CF <br />00001 <br />P <br />311 <br />P001 <br />W <br />�' <br />Medicine, solid, toxic, n. o. s. (Warfarin), <br />6.1 PG II ERG#151 <br />3. <br />4. <br />14.5pedalHandlinglnstructionsandAdditionallnformation 1.100196(RX Toxic Solids ) 2. 101079tResidue <br />weight does not <br />exceed 0.0436 lbs) CNT:7 <br />15. GENERATOR'S1OFFEROR'SCERTIFICATION: thereby dedarethat the contents of this consignment are fully and accurately described above by the proper shipping name, and are dassfied, packaged, <br />marked and labeledlplacarded,crnd are in all respects in proper conditlon for transpai according to applicable Intemationai and national govemmenhal regulations. If export shipment and I am the Pdmary <br />Exporter, I certity that the contents of Ods consignment conform to the terms of the attached EPAAckrawledgment of Consent. <br />i certify that the waste minim'Ization statement identified in 40 CFR 262.27(a) (if I am a large quantify generetor) or (b small quantity generator) is true. <br />n tot ero s tel�liy�ed am� __ e gna <br />on ay ear <br />Cn <br />G_i�,�vs` j„�W �{/� <br />01 09 201 <br />�.1 <br />76. Intema8onal Shipments ❑ Import to U.S. ❑Export from U.S. Port ofentry/exit: <br />�- <br />Trans orter si nature for ex rts onl Date leavin U.S.: <br />W <br />77. TrensporterAdmowledgment of Receipt of Materials <br />Transporter 1 Print !typed Name na u <br />on ay ear <br />O <br />a. <br />� <br />Phi Marcie! <br />n ay ear <br />Transpo r2 PrintedffYped Name �S� Igna <br />� <br />�� lf..c./r/ <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑Quantity ❑Type ❑Residue <br />❑Partial Rejek�on ❑Full Rejection <br />Manifest Reference Number: <br />18b. Aitemate Faclity (or Generator) <br />U.S. EPA ID Number <br />J_ <br />v <br />W <br />Fadl' s Phone: <br />Month Day Year <br />a <br />18c. 5gnature of Alternate Fadlity (or Generator) <br />z <br />y19. <br />Hazardous McOwd Codes (l.e., codes for hazardous waste treatment, disposal, and recyding systems) <br />iW_as�ie�Rjepjort�Management <br />20. Designated Facility Owner or Operator: Cer�ceOon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Signature .. <br />Month Day Year <br />� <br />Pdnte� Name � .� <br />L- <br />�rn nrc.T�.�.�r�n.l c.TATC /IG OC, 1111DCr1l <br />EPA Form 870D-22 (Rev. 3.05) Previous e0mons are oosulekC. <br />�t7AO1--�� i:�v� _f'ALr'7fIlfIf�1O164L 84101?�,O1�'i._, f141O►1 A9RA <br />UCJltal�rkl eU rn�.�u � e . v �+w. n.r.,.v+. v,r.. � 1.. ,.� ...,,...../ <br />M_ DTIA 191 A ._ _ RTlO►.f A�! i R _ <br />
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