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Please print or type. (Form des <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />350251 <br />i for use on elite (121 <br />Generator ID Number <br />8000260224 <br />TS' ��_II 11111118111SIIIGII{I <br />Page 1 of 3. Emergency Response Phone 4. Mar <br />1009246804 <br />CUS (STS) #16982 <br />10424 Trinity! Parkway, Suite B <br />Form Approved. OMB No, 2050.0039 <br />CClB (BIS) #16982 <br />10424 Trinity Parkway, Suite B <br />Stockton. CA 95219 <br />i. transporter � comp y rvame <br />8. Designated Facili Name and Site Addre U.S. EPA ID Number <br />ttericycle, Inc. <br />2670 Executive Drive <br />Indianapolis, IN 46241 <br />Facilit Is Pho <br />9a 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.Noi. <br />N3248, Waste Medicine, liquid, flammable, R 0001 P 311 D 01 <br />oxic, n. o. s. (Alcohol), 3 6.1, PG II, ERG# <br />.102966 (RX State Regulated) <br />15. GENERATOR'SfOFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are ciassi8ed, packaged, <br />marked and Iabeledlpiacarded,gnd are in all respects in proper condition for transport according to applicable intemalional and national governmental regulations. 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) (if I am a small quantity generator) is true. <br />❑ Import to U.S. <br />17. TransporterAcknowledgment of Receipt of Materials <br />18. Discrepadcy <br />18a. Discrepancy Indication Space <br />F118b. Alternate Facility (or Generator) <br />.a <br />U <br />LL FariliWQ Phnne, <br />� <br />19. Hazardous Waste Report <br />20. Designated Facility Owner or <br />Printed/Typ1ed Name /)mss <br />. i /0) •J, <br />Form 8700-22 (Rev. <br />Quantity <br />Method Codes <br />Certification of <br />editions are <br />❑ Export from U.S. <br />❑Type <br />codes for hazardous waste treatment, disposal, and <br />Port ofentry/exit: <br />Date leaving U.S.: <br />❑Residue <br />of hazardous materials covered by the manifest except as noted in Item 18a <br />❑ Partial Rejection <br />EPA ID Number <br />4. <br />❑ Full Rejection <br />+aFC36CaNA��lF1 IyACI'a.lTYit"? [}G�t"lh�P,TiCi'Pd SiAi� (iP !��C1Ui <br />