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r _. i <br />Please print or type. (Form des <br />TUNIFORM HAZARDOUS <br />WASTE MANIFEST <br />:d for use on elite (12-pitc <br />. Generates ID Number <br />CAR000262303 <br />CV5 (SIS) #16223 <br />2098333494 2800 Naglee Rd, Suite B <br />_���..,,��� oh,,,,e. Tracy, CA 95304 <br />1:171 <br />� X <br />0 <br />w X <br />I <br />1 l ��Ii Ill � <br />� IIS 1 I I 'i �. <br />�. '�; <br />�.,. �� <br />r •5', •�� <br />ITS .. 1_. <br />' 1� <br />1 � ' <br />1t; �;'I <br />i <br />CV5 ISIS)#16223 <br />2800 Naglee Rd, Suite B <br />Tracy. CA 95304 <br />Stericycle Specialty Waste Solutions Inc <br />porter 2 Company Name <br />ogled Fatality Name and Site Address 21st Century EMN, LLC <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />Phone: 7755752760 <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />and Paddng Group (rf any)) No. Type <br />UN2811, Waste Toxic solids, organic, n. o. s. 1 CF <br />(Chro�iu�, Seleniu�), 6. 1, PG II, ERG#154 <br />UN3249, Waste Residue Last Contained,. i <br />Medicine, solid, toxic, n. o. s. tWarfarin), <br />6. i, PG I I, .ERG#.151..,.... <br />�19�tRX Toxic Solids.) 2. <br />exceed 0.0436 lbs) CNT:12 <br />�.��o� ���3�°y►�s° <br />U.S. EPA ID Number <br />11. Total <br />12. Unit <br />Quantity <br />WtNd. <br />00001 <br />P <br />13. Waste Codes <br />3111D0071D010 <br />3111 P001 <br />Residue weight does not <br />t5. GENERATQR'SIQFFERQR'S CERTIFICATIDN: (hereby declare that the contents of this consignment are fully and accurately descdbed above by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are In all respells in proper condition for transport according to applicable international and national governmental regulatans. If export shipment and I am the Primary <br />Exporter, I certify that the contents of Otis consignment conform to the terms of the attached EPAAdknowiedgment of Consent. <br />i certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) a (b) (if I am a small quantity generator) is true. <br />� �c ,�' � ewn+�tYl <br />� 16. intematbnal hipmenls � import to U.S. ❑Export from U.S. <br />Trans orter si nature fa ex its oni <br />17. TransporterAcknawledgmentofReceiplofMatedals <br />�. �?1Y� V..: 1'10 v.a.��,�-. 1.. �:., <br />Transporter 2 Printed/Typed NName %� <br />��. <br />18. Discrepancy <br />18a. Discrepancy Indkation Space <br />18b. Alternate Fadlity (a Generato <br />V <br />la+- Fadl' s Phone: <br />W 18c. Signature of Altemale Fadlity <br />a <br />z <br />19. Hazardous Waste Report Mans <br />0 1. <br />20. Desgnated Fadlity Oymer or C <br />PrintedlTyped am i <br />EPA Form 8700-22 (Rev. 3.05) PrE <br />❑ Quantity <br />�: <br />Method Codes (i.e., codes for hazaMous waste treatment, di <br />12 � { t <br />Certification of receipt of hazardous matedais covered by the <br />are <br /><'T,t1 <br />Port ofentry/exit: <br />Date leaving U.S.: <br />❑ Residue <br />systems) <br />as noted in Item 18a <br />❑ PanSal Rejection <br />U.S. EPAID <br />DESIGNATED FACILITY <br />__ __:=8ZQ10-�2�-2�3.CAl��►090641-:=�541�1260E3, Q41�201650-� �:,"::--- -=°_- �-- _. _ - <br />❑ FuB Rejection <br />STAB'!: (IF <br />