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Please print or type. 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 CAL0004106 54 1 18775772669 013693893 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #15928 Dollar General#15928 <br /> 2097272100 12984 E. BLOSSOM COURT 12984 E. BLOSSOM COURT <br /> Generator's Phone: LOCKEFORD CA 95237 LOCKEFORD9 CA 95237 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMINS12100110924 <br /> 7.Transporter 2 Company Name {� U.S.EPA ID Number <br /> / <br /> 2 lL' 7 <br /> 8.Designated Facility Name and Site Address 21 st Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone: 895338 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> o X 6N1993, Waste Flammable liquids, n. o. s. 1 CF 00008 P 331 D@01 <br /> (Alcohol), 3, PG II, ERG#128 <br /> UJ <br /> X FJN3266, Waste Corrosive Liquid, Basic, 1 CF 00005 P 122 D002 <br /> Inorganic, N.O.S. (Sodium Hydroxide, <br /> Potassium <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 110518(Flammable Liquids - Loosepack) 2. 110515(Basic Liquids, <br /> Inorganic - Loosepack) <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 labeled/placarded,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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <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 I am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Nam` -, �A Signature Month Day .Year <br /> 16.International Shipments t��l/,�,Zp/ ��i�i. <br /> j.. ❑import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a Jared Marciel <br /> 1-49 1 IL41 16 Lei <br /> Z Transporter 2 Printed/Typed Nameignatuje Month Day Year <br /> {/jjf.� <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type yp El Residue ❑Partial Rejection E]Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> V <br /> LL Facility's Phone: <br /> 1 <br /> S 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> us19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> G <br /> /f/q- 14/� <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name � Q R ` � Signature � Month Day Year <br /> ' <br /> � 1vc, L,.c <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 8700-22_12v3 CAL20072032 S41053419 041565879 M _ - _PD1@1619_ - SD_1@1619 <br />