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Please print or type. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOTenerator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTL000410654 1 877577266` F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #1538 DOIlar General#15928 <br /> 2057272100 12384 E. BLOSSOM COURT 12884 E. BLOSSOM COURT <br /> Generator's Phone: L(7CKEFCIRD, CA 9337LOCKET CfRD CA S l�,s7 <br /> 6.Transporter 1 Company Name <br /> U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> General Environmental Mgt, LLC U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Facility's Phone Rancho Cordova, CA 95742 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10Containers <br /> HM and Packing Group(if any)) . 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> o X 1N1950, Waste Aerosols, flammable 2. 1, ERG#125 i CE 00006 p 331 1)001 <br /> w <br /> Z 2. <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1. 110541 (Aerosols) <br /> 15. GENERATOR'S/OFFEROR'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 /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> marked and labeled/placarded,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 /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if l am a small quantity generator)is true. <br /> Generator's/Offeror's Printed/Typed Name Signature <br /> Month Day Year <br /> ,j 16.International Shipments r <br /> Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of MaterialsLU <br /> Date leaving U.S.: <br /> Transporter 1 Printed/Typed Name <br /> pSignature <br /> W dared Month Day Year <br /> ZTransporter 2 Pdnted/Typed Name r11A i b ' 19Si�re <br /> F• Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection E]Full Rejection <br /> jZ 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> M U.S.EPA ID Number <br /> v <br /> LL Facilitys Phone: <br /> UO 18c.Signature of Alternate Facility(or Generator) <br /> Z Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1' 2. <br /> 3, <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of h ardous materials covered by the manifest except as noted in Item 18a <br /> Printed(Typed Name <br /> ISignature M th Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous ditions are obsolete. <br /> DESIGNATE ITY TO EPA's a-MA i ST SYSTEM <br /> n-�tan t•�.. rns 1r1rfA7�r7Y? C/.i fhe? d n <br /> PI/.4 G•/'Cl1�ff1 ..� <br />