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'Please print or type.(Form designed for use on eliteitch 12- writer. <br /> ( p )typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Genera&ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST AL000374267 11 75772669 011388659 F L E <br /> 5.Genarata s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #13568 Dollar General##13568 <br /> ?098233164 560 NORTH MAIN STREET 560 NORTH MAIN STREET <br /> Generator's Phone MANTECA. CA 95336-3900 MANTECA. CA 95336-3900 <br /> b. ransporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNS000110924 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 1r vvo38 <br /> 8,Designated Facility Name and Site Addres12I st Century EMN, &C U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone t's0 INV <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(f any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> oK JN1950, Waste Aerosols, flammable 2. 1, ERSM126 1 BA 00006 P 331 001 <br /> W <br /> Lu K IN19939 Waste Flammable liquids, n.o. s. F 00001 P 331 001 <br /> (Alcohol), 3, PG II, ERG#128 <br /> 3. <br /> 4 <br /> 14,Special Handling instructions and Additionallr-(Q,—malFDnI.PKG—DF:110541(Aerosols) 2. 110518(Flammable Liquids — <br /> _oosepack) <br /> 15. GENERATOR131OFFEROR'5 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 international and 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 EPA Acknowledgment 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/Offeror's Printed/Typed Name Month Day ear <br /> 108 117 019 <br /> .t f6.International Shipments <br /> ZLi Import to U.S. ElExportfrom U.S. Port of entry/exit: <br /> Transporter signature(for exports oniv) Date leaving U.S.: <br /> CC UJ <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name rg Month Day Yew <br /> 0 <br /> a- <br /> Jeff Hamilton 108 117 6018 <br /> Z Transporter 2 Printed/Typed Name r g Month Day Year <br /> 18.Discrepancy i <br /> 18a.Discrepancy Indication Space Quantity ❑Type yp F-1 Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S EPA ID Number <br /> J <br /> U <br /> a <br /> Farad s Phone: <br /> W 18c.Sign1 <br /> ature of Alternate Facility(or Generator) <br /> F Month Day Year <br /> z <br /> N19.Hazardous Waste Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> In 1 2 VAIq 1 3— 1 4. <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/Te <br /> YP�Na� ll -t Signature Month Day year <br /> ( C,Y tt 0- r /1n, n(IL � <br /> I 1I - \ I qI (01 it 0. <br /> EPA Form 8700-22(Rev.3-05) Prkdus editions are obsolete. DESIGNATED FACILITY UESTINATION STATE(fF REQUIRED) <br /> 8700-22_12v3 CAL29072032 S41053287 041154285 M PD081718 SDOB1718 <br />