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111�I�ltit'H�II��fI�I11�II��I�'11F. - `� <br /> 481035;18 r 002047472PSc '"��i� 3403945-601 <br /> ease not or Form des ned for use on elite(12-pitch) writer. / 1 Form Approved.OMB No.2A50-0039 <br /> P or type.{. g ( p )tYpe ) <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.P e o 3.Emergency Response Phone 4.Manifest Tracking Number- <br /> WASTE MANIFEST CAL000390053 <br /> r► (87x�577-2669 002047472 PSC <br /> 5.Generator's Name and Mailing Address Generatofs Sita-Address if different than mailing address) <br /> ORCHARD SUPPLY#1570 ORCHARD SUPPLY#1570 <br /> - 2650 N MAC ARTHUR DR. 2650 N MAC ARTHUR DR. <br /> TRACY,CA-95376(209)662-0192 TRACY;CA 95376 2096620192 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7.Transporter 2 Company Name y U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21st Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 14.Containers 11.Total 12.Unit 13. Waste Codes <br /> HM and,PackingGroup lttany)) No. Type Quantity Wt.Abi. <br /> 1, UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(METHYL ETHYL KETONE,ACETONE)3 PG8" 0001 D035 <br /> O <br /> � X 3 CW 4$0 P <br /> <C <br /> f� <br /> 2. UN1950 WASTE AEROSOLS 2.2(8)(EACH NOT EXCEEDING 1 LITER CAPACITY) D001 D005 13007 <br /> tom'? x 1 DF 127 P <br /> D035 <br /> 3. <br /> 4: <br /> 14.Special Handling Instnldans and Additional.Information <br /> (1)OSH3-07-ERG(128)OS143-07-FLAMMABLE LIQUIDS LOOSEPACK(2)OSH2.1707-ERG(126)OSH2.1-07-WASTE AEROSOLS <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 fabetedlplacarded,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 EPAAcknowledgment of Consent, <br /> A certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I.am a large quantity generator)or(b)lit i k a s quantity generator)is true. <br /> G6nqrato?VOfferofs PrintName month ay ear, <br /> 18 <br /> 16 international Shipments <br /> El Import to U.S. Export fromU.S. Port ofentry/exit <br /> Trans iter signature for exports onlft, Date leavin U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter PrintedlTyped Name ignature Month ay Year <br /> a" ChrisGilliarn �� 12 5 18 ; <br /> Z Transporter 2 Printed/Typed N ignature Month y ear <br /> t- <br /> G1�L�t100071 i <br /> 18:Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type' ❑Residue ElPartial.Rejection' Full Rejection <br /> Manifest Reference Number: <br /> 18b Aitemate Facility(or Generator) U.S.EPA ID Number <br /> ud. Facility's Phone: <br /> LU 18C.Signature of Alternate Facfl4(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposai,and recycling systems) <br /> UJ U' 1 H141 2 H141 3.: 4. <br /> 20,Designated FaCitity0wner or Operator:Certification of receipt of hazardous materials covered by the mandesf except as noted in item 18a <br /> Print dame r , Signature Day Year <br /> EPA Fo 8700-22(Rev. revious a ons are bsol e. <br />