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(1"........1.: ...1 F.. ..In.. /17 tori\4:rn triter\ <br />k,i.i <br />' <br />.:�.J <br />4. ManifestTrackingpNumber r e <br />I �'� it I ! ( (I 1�1 (� ( III �; �I � � I <br />y ��� li j l i '1 ( 1 �,'u r I� <br />r err � -r � � I ! 11 <br />Please <br />pnm �� ryNc. p v u ucu,y,,, u w, you v .._,,... \,� Y .v!7->iG •ye,/ ,... ,.- � „�. � . - :.._ <br />Pa 1 of 3. Emergency Res onse Phone <br />UNIFORM HAZARDOUS 1'GAlt�Q������t'1' � <br />4. ManifestTrackingpNumber r e <br />4 BQiQl��4���4 <br />O � C� O � � C7 � O � �C <br />WASTE MANIFEST <br />_ _ _ __ <br />5. Generators Name and Mading Address � Generators Site Address (ii di8erenl than mailing address) <br />' CVS (SISI #16982 :CVS (SIS)#15'38 <br />2092354'251 iQ�4c4 Tt,imity Parkway, Suite B. " 1044 <br />Trinity par kway, Suite B <br />� St ackt-on, GA 95219 St tack( <br />on, CA 55219 <br />Generetors Pnone: <br />U:S. EPA ID Number <br />6. Transporter 1 Company ame <br />Ster�icycle Specialty W�st.e Solut.ians -Inc <br />INN500�D110924 <br />7.Transporter2Com��arpe, <br />U.S.EPAIDNumber ���� <br />jV���jj r--' <br />� � �� <br />G,v <br />8. Designat aality Name and SlteAddress t e t" i C yc l:e � I T1C. <br />U.S. EPA ID Number <br />X670 ExectAtive Drive <br />Indianapolis, Ihl 462'41 <br />Fadlit�sPhone:3175545617 <br />II�R1�00110197 <br />9a. 9b• U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br />11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (i(ahy)) - No. Type <br />Quantity WtNol. <br />X <br />1UN2810, Waste Toxic, liq!tids, organic, rr. o. s. <br />1 <br />CF <br />��@tbi <br />P <br />311 <br />0034 <br />a <br />� <br />(Chloral Hydrate), 6. 1; pG TI, ERG#153- <br />X <br />2UN324@,. Waste Medicine,.iiquid, flammable., <br />i <br />CF <br />0►D00i <br />p <br />311 <br />D001 <br />� <br />toxic, n. o. s. (Alcohol), 3 6. 1, pG II, ERG# <br />�~ <br />iii <br />3. <br />} <br />t <br />4. <br />t <br />f <br />__ <br />14. Special Handling instructions and Additional In(ormalion 1. 1'01052 t RX Toxic Liquids 1 c. 1 G2966 (RX <br />State Re g I.tl at e d ) <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: T hereby dedaro that the contents of this consignment are fully and accurately described above <br />by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacarded, and are in all respeels in proper condition for transport according to applicable international and nagonal governmental regulagons. If export shipment and I am the Primary <br />Expoder, I cer8fythal the contents of this consignment conform to the terms of the attached EPAAcknovAedgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a largo quantity generator) am a small quantity generator) is We. <br />Generafo Ke s Pdnte y ed Nar� 9n a <br />on ay ear <br />�� <br />06 05 201 <br />D`- <br />16. International Shipments � Import to U.S. ❑Export from U.S. Port ofentry/exit• <br />Z <br />Trans otter sj nature for exports onl Dale leavin U.S.: <br />a <br />17. TranspoOerAdmox4edgmentofReceiptofMatedais <br />a <br />Transporter 1 Pdnted/ryped Name Sgnature �'r <br />Mont Day ear <br />i'''� =- <br />06� 05� X01 <br />a <br />Isidro, Mar inez _ <br />Mon Day Year <br />QTransporter <br />2 Pd' N Signature <br />� 1. <br />a <br />r <br />18. Discrepancy <br />18a. Discrepancy Indicelion Space � Quanfity � Type ❑Residue <br />❑ Pargal Rejection ❑Full Rejeclan <br />Manifest Reference Number: <br />18b. Ntemate Fadlity (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />�a+- <br />Fadl� s Phone: <br />Month Day Year <br />w <br />18c. Signature of Ntemate Facility (or Generator) <br />a <br />• <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste beaimeni; disposal, and recycling systems) <br />0 <br />1 2 3. <br />4. <br />�� <br />20. Designated Fadlity Owner or Operator. Cediticetion of receipt of hazardous materials covered by the ma ' cep( as noted in Item 18a <br />ih Day <br />i � <br />Pdnledlfyped Name '�_ 'goal re <br />�- <br />{ � �._..� <br />5 <br />ncarnr.rmc-cn enr+u rrV TA 11RCTItJ�T1f1N ATATt= IIF REQUIRE�I <br />EPA Form 8700-22 (Rev. 3-05) Previous eamons are oosolete. <br />r <br />