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Reviewing the Hazardous Waste Manifest <br /> The manifest tracks hazardous waste from the point of generation (your store) to the point of <br /> its ultimate disposal. It's part of the "cradle to grave" process. As the waste generator, we are <br /> responsible for ensuring that the manifest is accurate. Be sure to: <br /> Please print or"(Forin designed for use on eliite(12-pllch)Iypewnler) Form Approved.OMB111D5139 <br /> UNIFORM HAZARDOUS 1.Genera[rc IC Number ge 1 0 3.EmergenKy Responae Phone 4.M.4famt Trp J�u,g Number <br /> WASTE MANIFEST CRL000409667 1 775772669 012074856 FILE <br /> 5.Generators Name and Marmg Address C Qmlors SaaPdd lAdlaemr[Man m 41ng address) <br /> Verify that the EPA ID, Dollar Tree 06189 Dollar Treeit06189 <br /> (000) 000-0000 342 S. Indian kill Blvd 342 S. Indian HIll Blvd <br /> store number, and G.o .rs P­ Claremont, CR 91711 Claremont, CA 91711 <br /> e ranspwlerlmpany Name U.S.EPA ID Number <br /> address are correct. 6tericycle Specialty Waste Golutions Inc MN <br /> '00el101324 <br /> 1.Tmnapo r2 Company Name II.S.EPA ID N­ <br /> L11 , U.S.EPA IDW—, <br /> 2095 Newlands Dr'. East <br /> Fernley, NV 89408 <br /> F,Oi ,F�7755752760 INVD980995329 <br /> 9. 9b.U.S.oCT OeS pw(odw ng Proper Snyprg Name,H—d Class,to Number 10.Ct,,M nem 1I_Tptpl 12,UR 13waste codes <br /> HM antl Pack'mg Group In anYll Nb. Type Oua" WINp.'. <br /> d5 a amend a 1QUi 5, B.D.a. <br /> o fRcetone. MethvI Ethyl Ketone). 3. PG II. <br /> RGi1128 <br /> Review the type/weight z Waste Rerosols, tiammarme et, 1 3P WIRM PJI01211 <br /> of waste picked up. mm <br /> Weight is typically ' <br /> noted in pounds (P). <br /> f4.5pedel NeM'rng lnstrudibnsand Addirmal lnfobnalbn — . ammd a lq U1 s — er0 s0 S <br /> Verify the date is 15 GEN ER TOWWOFFENORSCE riCATION I hereby declare Mal the wntenls d Na mnsgnment are mly am as tai,tle bed app a by Me proper shipping name.and GarsW,pa ageQ <br /> markM end IabeleNpUQardetl,antl sae in aEl n.reels In proper WndMn Ipr hprgpprl acCatlilg b apptieabl0 mtemadona€and rellw+a€goyanllnentanegula!'bns.II export shipment aM 1 a€r dla Primary <br /> correct. Legibly print, ENoarlced eat��en�olh,swnpgn enl�{� letM1esm�plheapedEPAA�nppad�enter�pe¢l <br /> wrt'Ity Ural lna waste mirymizat'Iwa ant ldant{fiad in qq CFR 262,Zr[a)[Vf lama targe Ouangty gerleremrl or(h)II(lama all quanliry ganeramr7 as hue. � <br /> and then sign your G °hPo 'Na t _ amen pmar <br /> � es - Ia <br /> name. ,G.Inlame Gdp <br /> ImpDrt tp US. ❑E pod hom 11.5. —PO Df¢nlrytQKiC <br /> — ran oder sl nMam DnI Dam€aa>: u. <br /> W 1].Tranapol 0.cYn *dWm f Rettpl of Materna, 144E jou <br /> C mrtsparterl - n red g 2 ay Yr <br /> a Salvador Guzman 12 0f 18 <br /> 2 Transpoder2PenledlFyped Name a MDn[M1 y Year <br /> P <br /> 1 1 q.oisaePas�y <br /> I 1Ba.dgpeparq€r Fralgn Space ❑0—lit, ❑T" ❑Residue ❑Pedal Rgec€ibn F II Rejmllnn <br /> k+ani/es[Relemnce Number <br /> 1 Be Alkrrlala Faciny[a Genemlorl U.S.EPA ID Number <br /> V <br /> la4- EBpli s Phone. <br /> C 18c.SgnaMe DIINNanel¢Faddy(d GPTeratar) Me* Ody Year <br /> a <br /> x <br /> h <br /> 19_HeTarcbus Waste Report Maragam¢nl Memos Codes(re..twtles(orharardDus waste­rt dspbssl.ab recycling systems) <br /> 2g.De_sigoaled fad dy owner or ow—Cerefiealion W—PI Of hwoN &matenals—od by to maniMsl¢a[t pt os noted in II¢m 1 RA <br /> PnnledlT e , Sign Mgng1 Oa Y <br /> EPAForm8700-22(Rev.3-05)Previousedoonsareebselete, L DESIGNATED FACILITY TO DESTINATION STA L tIF REQUIRED) <br /> ci <br /> Within 30 days of the pick-up, you should receive a final manifest in the US mail. Signatures at the bottom <br /> (like those above) verify that the waste was received at the disposal facility. Staple this final manifest to <br /> the initial manifest and place them in the "Manifests" folder or binder. Retain both manifests at store <br /> level for 5 years. If a final manifest is not received within 30 days, notify hazardouswaste@dollartree.com. <br /> Important: Our vendor provides copies of the manifest to DTSC (a CA state agency) <br /> on behalf of Family Dollar and Dollar Tree. <br /> Hazardous Waste Quick Reference Guide 9 April 2019,ver 1.0 <br />