Laserfiche WebLink
75806-12 Nov, Illllillllllllllllllillllllllllllll! l �O.7 /" 1560550-001 <br /> Please Print or type.(Form desi ned for use on elite(12 latch) pexrtec) Form Approved.OMS No.20540039 <br /> !^ UNIFORM HAZARDOUS 1.Generator 1D Num:sr 2.Page 1 of i Emegency Response Phone .N^nest raking Npmber <br /> WASTE MANIFEST CAL000374268 (877) 577-2669 000432959 PSC j <br /> 5.Geramlors Name ant falling Addmss Gebmatys SR— er mare% d 6�wemman mating sddress <br /> DOLLAR GENERAL DOLLAR GENLRAL#"3593 <br /> 4232 E Main 4232 E Main <br /> f Stockton,CA 95215(209)8008822 I Stockton,CA 95215 <br /> Generators Phone. ' <br /> 6. ran er I Company Name U.S.EPA IO Number <br /> 21st Century Environmental Management of California, LPSAR000210617 <br /> 7.Transporter 2 Company Name t 5(� U.S.EPA ID Number l 3 33 <br /> V <br /> 6.Designated Faci sty Nam,and Sae Address U.S.EPA ID Number 7J <br /> 21st Century Environmental Management of Nevada,LLC NVD980895338 <br /> 2095 Newlands Dr.East <br /> Facility Phone: Fernley NV 89408 (775)5752760 <br /> � <br /> 9a. 9b.U.S.DOT Description(miudtg Pram Shipping Name.Hazard Class,10 Number, 10.Contakam 11 Tat, 12.Unit 13.Waste Codes <br /> HM and Packing Group Of any)) NO. Type ,r commety WtAaw. <br /> 1. D001 331 <br /> UN1950 WASTE AEROSOLS 2.1 INNER CONTAINERS MUST COMPLY WITH DOT <br /> O X SP 11296 1 DF 7 P <br /> z 2. 331 ) <br /> w _ <br /> � NON RCRA HAZARDOUS WASTE LIQUID OILS,DETERGENTS 1 DF ? P <br /> 3 , <br /> y <br /> a. <br /> �gg MAY <br /> (1)D�G2.140a.ERg126)dAEEROSOLS(2)DGnal 1lRm ERGO NO"CRA PRODUCTSS <br /> ` � � 1i l� ENVIRONMENTAL <br /> HPA%T41rW0AgMA;: (T <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I bereby dedsrethal the contends of this consignment we arly alfa accurate.y described above by the proper shipping name.and areclassified,packaged, <br /> marketl and Mbeledtpacarded,and are in as repnecls in proper coridibm far tmnlapwt according to appli bte intpmational ant national govemmemal mgulabons.a export shipment ant I am 9w Primary <br /> Exporter,I candy Nal he contents of the wroggnmem contain to the forms of the attached EPAAcknovdcdgmwt of Consent. <br /> I ced8y that the waste minimization statement identified in 40 CFR 262.27(a)til I am a large wantsy generator)or(o)hi I am a small guanbty generator)is We. <br /> ane a eras n y ami ern e o ay Year <br /> Do /c in/G�cl G 1 l <br /> –z 16.kternwon01 - mems ❑Impar U.S. ❑Exeon hon U.S. Pod ofeM7lepl:_ <br /> Transocater slnature for ex its only): 011e—1- U.S.: <br /> W 17.Transpurlor Acknmoledgmwd of Receipt of Materials <br /> Transporter 1 printmayped Name gna,ure <br /> R Joe tlueipo I I �— I /a <br /> Z Transpo2 NmedRypeo Name gnmum o eer <br /> OWL 113 <br /> rter <br /> t18.Discrepancy <br /> 1 ga.Discrepancy ladcation space ❑ opentity ❑Ty, El Residue ❑PaNd Rejecti. [I Fall Rejection <br /> Maniiesl Relmence Number: <br /> 1 W.Alterra[e Felty(ar Gemalw) U.S.EPA ID Number <br /> J <br /> V ' <br /> LL Fadfit s Phone: <br /> W 1&.signature of Niemela Facility lar GKW400 Mordh Day Vcar <br /> Q <br /> S2 19.Hazwdi Waste pecan Management Method!Codes(i.e.,codes far hezerdous wane ecatmeN.dsposal,and recycling systems) <br /> 0 1' 2. 3, a <br /> H141 H141 <br /> 20.Designated Fwify Dana,w Operatw:Cerfifiwtun d receipl of hazardous mawbala covered by manger except as noted In nem t ere <br /> YPed Name Sigrelwc Year <br /> �vv, 2 911311131 <br /> y <br /> EPA Form 870022(Rev.3-M) Previous edgions are obsolete. <br /> 01-31-13P01 :29 RCVD / 1 <br />