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Please print or type. (Form designed for use on elite (12-pitch))ypewriter.) ERT <br />TUNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. <br />WASTE MANIFEST AR0@026@224 I <br />CUS (SIS) #16982 <br />1 1@424 Trinity Barkway, Suite B <br />Stockton, CA 95219 <br />Ster;icycle, Specialty Waste Solutions Inc <br />tericycle, Inc, <br />2670 Executive Drive <br />Indianapolis, IN 46241 <br />9a. 9b. U.S. DOT Oescdption (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />ase a kine, >.qru , aiea e, <br />oxic, n. o. s. (Alcohol), 3 b. 1, RG II, ERG# <br />31 <br />3. <br />j e�s4 nse Ptwne �a. mannsl 1�_�ry9� 6 7 7 F <br />.1029f�6(RX State Regulated} <br />CVS (SIS)#16982 <br />1@424 Trinity Barkway, Suite B <br />5tocktan, CA 95219 <br />NS00011@924 <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />' NR0@@110197 <br />10. Containers 11. Total 12. Unit t3. Waste Codes <br />11 D <br />owl 4 <br />No. Type Quantity WI.NoI. <br />'J <br />DEPARTME��T <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 labeledlplacarded,and are in all respects in proper conditwn for transport according to appl'�cable international and natbnal governmental regulations. If export shipment and Lam the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment o(Consent. <br />certify that the waste minimization statement identified in QO CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />na ure on ay <br />Generato s Offer s rintedlTyped ame - <br />6. International Shi ents � ' Im ' rt to U.S. ❑ Ex from U.S. Port of entrylexit: <br />17. Transpoder AcknovAedgment of Receipt of Materials <br />Z Trans rter 2 Printed/TZpetl me /� �/ / f/ <br />1 B. Discrepancy <br />18a. Discrepancy Indication Space � Quantity ❑Type ❑Residue ❑Partial RejeGion <br />Man'dest Reference Numher: <br />U.S. EPA ID NUmbl <br />18b. Alternate Fadlfty (or Generator) <br />J_ <br />V <br />la+- Facilit s Phone: <br />w 18c. Signature of Alternate Fadlity (or Generator) <br />Q <br />Z <br />N 19. Hazardous Waste Report Management Method Codas (i.e., codas for hazardous waste Uealment, disposal, and recycling systems 4 <br />2 3 <br />0 1• <br />20. esignaled Facill Owner or Operator. Cerfification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Sig to /` <br />P' ted/Typed Nam � <br />EPA Form 8700-22 ( .3.05 P vioits ions are obsolete. - <br />A7AA—J`S 1 O.,Z f'N 4fkf11D6ta s ni. a nr,rn,a -� fqt. a a nr.,+., -• •• <br />❑Full Rejection <br />�•�c;?L.ITY Tt� iaES7jPiAi1'10�! STATS f!F REQU <br />