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WON <br />11M IN114P <br />Please print or Form designed for use on elite 12- itch writer. 1111 Form Approved, OMB No. 2050-0039 <br />Ple P h'Pe ( 9 ( P ) "writer.) ERT PP <br />UNIFORM HAZARDOUS 1. Generator ID NumberPage 1 of4092468112114 <br />Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST ARa002, 26@224 1 011392678 F L E <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />CVS (SIS) #16982 CVS (SIS)#16982,1 <br />092359251 10424 Trinity Parkway, Suite B 10424 Trinity Parkway, Suite B <br />Gehetafor's Phone: Stockton, CA, 95219 Stockton, CA. 95219 <br />6. Transporter i Comps'ny1�ame" U.S. EPA ID Number <br />Stericycle Specialty Waste Solutions Inc NSSOOLI0924 <br />7, Transporter 2 Company Name L U.S. EPA ID Number <br />C /r" Cyt C 'l �t1i 7' 6M 017047ra6? ir `?49g " <br />8. Designated Facility Name and Site AddresC AS Z Century EM, LLU U.S. EPA ID Number <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />Facilitys Phon7*.755752760 PVD980895338 <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 />ase loxic solids, organic, n. o. s. 1 IF 0001 P 31.1: E007 D211110 <br />o Chromium, Selenium)., 6.1, PG II, ERG#154 <br />Z 2. <br />ui <br />3. <br />4, <br />14. Special Handling Instructions and Additional Information OX 1C 5 0 11111 5 <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, 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 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 EPAAckrwwiedgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />erasofferors Pn'ntedrryped Name Signature Month Year <br />1218 <br />.J1 16. ftmational Shipments <br />F— mport to U.S. Export from U.S. Port of entry <br />Z Transporter signature for exports on : Date leaving U.S.: <br />NIFENESSIN <br />W 17. Transporter AduwMedgment of Receipt of Materials <br />LLITransporter 1 Printed/Typed Name Signature Montay ear <br />ristopherAlmanza 8 (31 18 <br />a <br />Transporter 2 PrintedlT Name Mon <br />in <br />tay ear <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Aitemate Facility (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />LL Fadii s Phone: <br />w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />2000001 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 1. � T <br />3. 4, <br />1111: -- 1 <br />20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name _ Signature Mon �y Year <br />REQUIRED) <br />EPA Form 8700.22 (Rev. 5) Previous edition are obsolete. DESIGNATED FACILITY To <br />STINATION STAT i <br />