Laserfiche WebLink
Pfease print or type Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I.Gerierator[DNumber 2.Page I of 3.Emergency Response Pnone 4.manifest Trac)dng Number <br /> WASTE MANIFEST GAR k1276325 I I 67'15/72669 013658226 FLE <br /> 5 Generators Name and Mailing Address Generators Site kdress(if different than mailing address) <br /> Dollar General #1.3357 Dollar General#1335-1 <br /> 2092531664 1201 WEST MAIN STREET 1201 WEST MAIN STREET <br /> Generator's phone: RIPON7 CA 95366--30i` klPON, CA 95366 <br /> 6,Transporter 1 Company Name U.S.EPA o Number <br /> Stericycle Specialty Waste Solutions Inc., MNS01601 10'3ia4 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> ')'-- <br /> 8. <br /> OC <br /> Designated Facility Na n and Site Address Y u ma Yes, LPC j U.S.EPA IQ Number <br /> 2730 E. 13th Street <br /> Yuma, AZ 85365 <br /> Facility's pme9286428938 JALROAO l51b924 <br /> ga. 9b.U.S,DOT Description(inctling proper SNPOng Name,Hazard Class,ID Number, 1C.Contamers it Total 12.Um <br /> HIM and Packing Group(if airy)) NO. Type Quantity wtjvoi. 13.Naste Codes <br /> Ion RCRA hazardous waste, liquid (Consumer 4 DF 00446 P 331 <br /> --'roducts), <br /> 2, <br /> LU <br /> 3, <br /> 4. <br /> 14,Special Handling Instructions and Additiorial Infara"atiOn 1. 11 1111b24{Non--RG RSI Liquid Waste (GA Only) Loosepaick) <br /> 15. GENERATOWS10FIFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accwately described above by the pro*sNpping name,and are ct3ssftd.padEaged, <br /> marked and Jabeled(placwded,and are in all respects in proper condition for transport according to applicable international aM nalsonat governmental regulations,If expon sNpment and I am the Primary <br /> Exporter,I oerfifie that the contents of this consignment conform to the terms of ft atWd*d CPAAcknowledgment of Consent <br /> I oe"Vial ft waste mininitzation statement kientified in 40 CFR 26227(a)(41 am a large quantity generator'}or(b)(01 am aVW,1quariRqgenerator}is hie, <br /> Genu PrintediTyped Non Sg Month Day Year <br /> interrtatrcnrnal 08 Ln piq <br /> 16- <br /> Import to U.S. E]Export from U Sy Port of enq'Oxit <br /> Transporter signature(for exports only): Data leaving U.S <br /> W 17.TrarspVwAdToMedqrW of Receipt of Materials <br /> W <br /> Transporter I Prriledffypad Name Signature i moth Day Year <br /> RJaced Marciel <br /> (n k)8 I e3 kol r <br /> z ) <br /> Transporter 2 Pr Name Writh Day TE7— <br /> nA 0'7-cc- <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space quantity 11 Type [I Rd. El Partial Rejection DO Rejection <br /> Manifest Reference Number; <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Li <br /> FdfiYs Ph..: <br /> Lu 18c,Signature of Allemato Facility(or Generator} Month Day Year <br /> 19,Hazardous WasteRepotManagement Mettiod Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> Uj 1 2, 3. 4. <br /> Lh LA I I 1 1 <br /> 20.Designated Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> gnatnne <br /> PrinteeliTyped Name Day year M rJq It I I <br /> EPA Form 8700-22(Rev.12-17)lpmvious editions are obscWe, DESItNA 71 AOLITY TO EPA's e-MAN;FEST SYSTE <br />