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429779 Please print or type. (Form designed for use on elite (12 -Ditto) tvpewrfter.) gT�0B4B Fnrm Annroved OMB No. 2050.0039 u.- -« t a, , v l UV LA,b eumUnb are ousoiete. UESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trackin Number U WASTE MANIFEST CA R000213561 2 ( 077) 577-2 69 00 0 0 6 2 5 DAT 5. Generator's Name and Mailing Address Generator's Site Address (it different than mailing address) Rite Aid SO5996 Rite Aid 185995 4y lU5{{55II No h III Vf284)448-0950 it��k�rt-�R W01 169)918-Im Generatdffan)n 6. Transporter 1 Company Name U.S. EPA ID Number 21st Century Environmental Management of Neva(la, LLC NVD980895330 7. Transporter 2 Company Name U.S. EPA ID Number 21st Century Environmental Management of California, LP CAR000210617 8. Designated Facility Name and Site Address U.S. EPA ID Number GENERAL ENVIII)IMENTAL NGT, LLC BBA PSG ENVIRMENTAL SERVICES 11855 UNITE ROCK ROAN Facilitys Phone: VHM CGRIMY9, CA 1115742 1910 3SI-1100CAD 80 84183 ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WI.Nol. x 1. U1111950 BASTE AEROSOLS, FLIAI9fAILE2.1 �li5 Be a:;;;rrm�, n (�f 118I1 D007 BOBS X Uffli ,,,,t Sp 44-Hrr p IBIS long 311 z z -1 qWnruvri _. "�7T� 3. mEfdiv 41.94 NOW - M_ r r , - . 4. W. Special Handling Intro r�pd Additional Information L (1) RITEAI1 .1-R1 - ERG(126) AEROSOLS-ACCUNULATIO (311-41=13 "' -FR64 H) rwIlIkE nnrrnnnv f,t pT1[nTn�c , a1 r�r10""HifffIffle �=E 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, marked and labeledlplacarded, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (d I am a small quantity generator) is We. GeneratorslOfferoes Printedffyped Name Signature Month Day Year �-+ 1 -.r Z 16.lntemational Shipments ❑ Import to U.S. ❑ Export horn Pod of e - Transporter signature (for exports only): Date g U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Tra iter 1 PdntedlTyNAL/-kD Signature Month Day Year n a Transporter 2 Pr ntedf(yped Name tgnatu Month Day Year oC H 18. Discrepancy 188. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID J_ Number U Facility's Phone: 18c. Signature of Alternate Facility (or Generator) Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recyciing systems) w C 1 2. 20. Designaled Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year u.- -« t a, , v l UV LA,b eumUnb are ousoiete. UESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED)