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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS, 1AGeneralorIDNurrL r 2iPage1of 3.Emergency Response Phone 4.Manifest Tracidnor
<br /> WASTE MANIFEST I CAL1100374287 1 � 1677577P-669 I 0081;48716 F L.E
<br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address)
<br /> Dollat% Seneral t4356$ Dollar GeTler�al#i2,���5
<br /> MUZM41 580 NORTH MAIN STREET `°.r'. � - 560 NORTH MAIN STREET
<br /> Generators Phone: MANTECA, CA 95336-3900 I - MPNTECA, Cil %3 X36-39@0
<br /> 6,Transporter 1 company Name U.S.EPA ID Number
<br /> Storicycle Spar ialty Waste Solutions Inc 1 M$101100110924
<br /> 7.Transporter 2 Company Name .U.S.EPA ID Number
<br /> i
<br /> 8,Designated Facddy Name and&teAddress IIJQT,l LLU U.S.EPA)D Number
<br /> 118-55 White Rock Road
<br /> RzztTlcho Cordova, CA 55742
<br /> Fadrll�?s Phone:9153 10S�ll�l ' , I CAI' 8 4183
<br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, ` 10.Containers 11.Total' 12 Unit 13,Waste Codes
<br /> HM and Packing Group(d any)) No, Type Quantity WtNol
<br /> x
<br /> �� r,.•a tnv1ronraontally hazardous I CF X0003 P 1.81h00g
<br /> substances, solid, n.o.s. (Mercury, Broken
<br /> 171t1orDSCen4 1-In4t •TEtha ). 9. [7 ITT. PPRW71
<br /> LOU X 'UN19501 Waste Asrosols, flammable 1, LR0*126 I CK 00015 � 331 11�147j1
<br /> X ON 1993, Wasto Flammable liquids, n.o.s. I DM 00034 P 331 111001
<br /> ((alcohol), 31 PS 11, ER13*128
<br /> ' Non RCRP hazardous viaste, liquid (Consumer 1 AF 00iop- P 3�1
<br /> brad stat s),
<br /> 14,Special Handling lnstructionsandAdditlonallnfarma on 1. U054404erc,ury Containing Waste {Broken FllttJrescty73.t Lamp))
<br /> 1105-`11 (A0rras0lt;) 1+ 110518(Fliawmable Liquids w Loasepaclo 11. 1i0524(Non--RCRA Liquid Waste
<br /> (CA Only) - 1.00sepack) '
<br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION,I hereby declam that the oonienta dthh�o3mgnment are hully acid aceuratelydescrbad above by the propershl%lrig name,and are classirred•packaged,
<br /> marked and(ebetedfplaeardad,and ars In a8 r"cls in proper ca W&m for bansport aoeacd;ng to app icalxe international and national governmental mg0obons If rxrpart shipment and I am 1ha Primary e
<br /> EVorter.I that the oorilentsof tlilscanalgrrpar4 oarrfurm to the terms of the attached EPAAcknowledgment of Consent,
<br /> I Car*that 14wasio ntir1mizailen stalemerdidenL6ed m 49 CFR 262.27(a)(if I am a large quantity generator)or(b)(f i am a small quantity generator)is two.
<br /> C-4nerawafolfar Pariamsignature - onto ear
<br /> 1 r n,)C? , C-7)C�cc, aa' I ,QF. 1 07 lag 1-2
<br /> .-.r 16,Intemalldh I'SNPlnenis' t
<br /> t+ ❑Import to U S ❑Export from U.S. Part of entrylexit.
<br /> ? Transporter sianature(for exports only): Date leavm9 U S,
<br /> a 17,Transporter Acknowledgment of Receipt ofMatenals
<br /> Transporter 1PnntecvIypeciName •'ignature t Imonth Day Year
<br /> 9 .Tr i� ed l''icarciel I 061 L47 k-011
<br /> a Tmnsporter2 Pnnledfryped Name Sign1diure Month Day Year
<br /> h I I I I 1
<br /> 18.Discrepancy
<br /> Resdue Partial Rejection18a.Discrepancy Indication Space Quantity ❑Tye El Full Rejection
<br /> Manifest Reference Number
<br /> 18b.AltdmatoFacility(or Generator) US EPA ID Number
<br /> w FacilitVa Phone* f
<br /> 18e.Signature ofAltemateFacility(of Generator) Month Day Year
<br /> 19.Hazardous Waste Report Management Method Codes(r e,codes for hazardous lwaste treatment,disposal,and recycling sys
<br /> tems)
<br /> )
<br /> G 1 ! L-Jf �2 Y4 ! �1 �3 t 9
<br /> 44r `H � t
<br /> 20,Do/siygn e� aality,Ow7pil Name ner or bperator.Certification of receipt of hazardous materials covered tjy the manifest except as noleq in 1018a ` f i
<br /> { �I! � f 1 , /. .t f' -! I Signatore f �!' s.7�� 1 �o -7
<br /> i
<br /> Form 8700-22 Rev.3-05) Previous editions are obsolete. J �SIGN&99-ACILITY TO diNtRATOR STATE(IF REQUIRED)
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