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Please print or type.(Form designed for use on eliteitch <br /> 12- <br /> ( p )typewriter.) ER P lip Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST Address 373076 1 8009246804 0 0 8 6 6 4 8 8 4 FL E <br /> 5.Generators Name and Mailing Address Generator's Site Address(a different than mailing address) <br /> Dollar General#13592 <br /> .12098008820 310 W DR KARTIN LUTHER KING JR <br /> Generators Phone: STOCKTON •CA 95206-1763 <br /> mnsporter mpany ame <br /> U.S.EPA IQ Number <br /> Zteric cle Speci.alty Waste 5alutions Inc hfNS000110924 <br /> 7.Transpo r2 Name <br /> U.S.EPA 10 Number <br /> S.Designated FactlityName sltaAddress General Environaent 1 Mgt, LLC U.S.EPA ID Number <br /> 11855 White­Rack Road <br /> Rancho Cordova, CA 95742 <br /> Faoli s Phohe:.916351$980 CAD980884 8 <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Gass,10 Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit <br /> No. Type Quantity Wtivol, <br /> 13.Waste Codes <br /> ,r X 1•UN1791, Waste Hypochlorite Salutians 8, PG 1 DF0013$ P i 2i D002 <br /> .III, ERG#154 <br /> LU <br /> w 2- an CRA ha—zardous waste, liquid (CDnsuoer 2 DF 00289 P 331 <br /> Products), <br /> 3. <br /> a. <br /> 10.Special Handling Instructions and Additional Information 1 each, i q u 1 d, Non—RC RA Liquid Waste (CA <br /> Only) •- Loosepack) <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:i hereby declare that the contents of this consignment are tufty and eoturatety described above by the proper shipping name,and are wed,pec aged, <br /> marked and labeladIptacarded.and are in at respects in proper condition for transport according to appkabie irtemaborel and national gowernmenta! <br /> Exporter,l certify that the contents of this consignment conform to the terms of ft attached EPA Acknowledgment of Consent. Mian.If export shipment and I am the Primary <br /> I certify that the waste minimization statement idenffW in 40 CFR 26237(a),(d I am a large quanfiry generator)or(b)((if I ant a s quantity generator)is true, <br /> ame g�0 <br /> :nT,eras <br /> 09 22 201 <br /> lmpat to U.S. Export from U.S. of enbylexdtre on : <br /> 17.TransporterAdowwI*ment of Receipt of Materials U.S.: <br /> Transporter I PninWyped Name <br /> Ian. Kri_sto her Al.fill y �n <br /> g� onCt ay ear. . <br /> tea.Discrepancy Indication Space U Quantity ❑Type <br /> ❑Residue ❑Partial Rejeetion ❑Full Rejection <br /> 18b,Altemate FaeLty(or Generator) Manifest Reference Number <br /> -� U.S.EPA 10 fturnber <br /> U <br /> Q <br /> r+ Faali Phone: <br /> 0 18c.s gnature of Alternate Facility(or Generator) <br /> z Month Day Year <br /> w19.Hazardous Waste Repot management Method Codes(i.e..codes for hazardous waste treatment disposal,and mcydkv systems) <br /> 0 1 ( 2. 3. <br /> d. <br /> 20.t7esignatad Eaalaty Ow+her a Operates:Certification of receipt d hazardous materials oovered by the rnanifest ex <br /> PrintedrTyped Marna except as rated In Item f <br /> L'LS Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. / <br /> tiNATED FACIIdTY'TO DESTINATION STATE(IF REQUIRED) <br />