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Please print or type. I Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest TrackiNumber WASTE MANIFEST CAL000018659 1 8775772669 012663148 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Kmart #3174 Kmart#3174 2099488205 2180 E Mariposa Rd 2180 E Mariposa Rd Generator's Phone: Stockton, CA 95205 Stockton, CA 95205 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number �� 4 & L off' ©� 8.Designated Facility Name and Site Address U.S.EPA ID Number 2095ewlands Dr. East Fernl#y, -NV 89408 Facility's Phone: 7755752760 NVD980895338 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quanfity Wt.Nol. 13.Waste Codes a: _-MUN150101, Waste Perosols, LT141111111111111able, each not 1 CF 00025 F' 331 D601 0 exceeding 1 L capacity)] 2. 1, ERG#126 w Z 2. W 3. 4. 14.Special Handling Instructions and Additional Information 1. 100901 (Aerosols) 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, 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 Exporter,I certify that the contents of this consignment conform to the terms 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)(if I am a small qAntity en tor)is true. Generator's/Offeror's Pn ted/Typed Name Signature Month Day Year nj lr! .International Shipments 03 12 201 Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printed/Typed Name Signature 9 Month Day Year a Kristopher Almanza 03 1212@1 Z Transporter 2 Printed/Typed Name Signature Month Day Year ;9 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑ ❑ Type Residue ❑Partial Rejection El Full Rejection , Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U I Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1 \-V\kA\ 1. 2• 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typ aName Signature r• Signat t Month Day Year C41 19 EPA Form 7 0-22( ev.12 17) Previous a (tions are bbiolete. 3 DESIGNATEb FACILITY E 's e-MANIFEST SYSTEM 8700-22�12v3 CAL20070093 S40059123 041347094_ M_ PD03i21.9 snoa1a1q