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Please e <br /> print or type.(Form designed for use on.,Ihe <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gareratq;ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CI-AL 000 3;7 42G7 r 75 f"2E � 010168922 F L E <br /> 6.Generals"Name and Nlawng Address Generator's Site Address(if different than mailing address} <br /> E1llar` General #i-568 Dollar- General#175EZ <br /> k'f8`_ :tE4 560 NORTH MAIN STREET 5G@ NORTH ±CAIN STREET <br /> Generator's Phone: 'IAN(ECA, LA 95.336-3900f�s.-.�� <br /> MAP�i-rEcA. CA 6--7-1,91010 <br /> 6.I ransporter t Companplame U.S EPA ID Number <br /> Ster icycle 9 0ecialt baste Solutions Inc (hit�lS000110":'4 <br /> 7.Traasparlar 2 Company Name U.S.EPA ID Number <br /> 40 v`' <br /> 8._D899-nateiJ Facility Name and Site Address Gen era I Environmental Mgt,, L., U.S.EPA tD Number <br /> 11855 White Rock Road <br /> Rancho Cordova. CA 95742 <br /> r"adlit sPhom'91G, 519980 1 CAD:+80684183 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1'J.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any;} No. Type Quantity Wt.Nol 13.Waste Codes <br /> ICY- X ON1993, Waste Flammable liquids, n. o. s. 1 DM 00051 P 331 1 <br /> (Alcohol), 3, PG II, ERG#128 <br /> X RiN2610, Waste Toxic. liquids, organic, n.o. s. 1 DM 00114 P 331 ID005 <br /> (Barium, Permethrin), G. 1, PG II, ERG#153 <br /> i <br /> X UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 <br /> CF 00023 P 331 D0k71 <br /> Non RCRA hazardous waste, liquid (Consumer 1 DF 0005 P 331 <br /> Products), <br /> 4.Special Handling Instructions and Additional Information 1. 110518(F 1 a m ma b i e Liquids •- L o+o s e pac k) c. 110527(Toxic L i 4 u i d s <br /> - Loosegack) 3, 110541 (Aerosols) 4. 110524(Non--RCRA Liquid Waste (CA OP10 LooselI <br /> 15. GENE RATOR'WOFFEROWS 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 expos shipment and I am the Primary <br /> Exporter,i certify that the contents of this consignment conform to the terms or the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(x)(if I am a large quantity generator}xeF'(b)lift am a small quantity generator)is true, <br /> n Name :/t Signa ti Month Day eat <br /> ` <br /> i 16.International Shipments <br /> 1— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> TranspoW signature(for exports onlv}: Date ieavinq U.S.: <br /> w17,Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name gna a Month Day Year <br /> n- Mat+r+icl tlr: �r`h Oil 7 <br /> z¢ Transpo ter 2 P rted Typed Name Signature t 1 Month ay I— ear <br /> Q: <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space LD ;� �i <br /> Quantity El Type LJ Residue ❑Partial Rejection L__J Full Resection <br /> Mantles[fiefe eroe Number <br /> IAb.Memo Is Facility(or Generator] U.S.EPA ID Number <br /> v <br /> a <br /> � FaciU 's Pham: <br /> 18c Sipnalure of Nternate Facility(or Gan&III } Month Day Year <br /> 4 <br /> 0 <br /> 01 1 1 <br /> 18.Hazardous Waste Report Management Medtod Cozies Le.,oo&s far hazardous waste treatrr*nL <br /> +►� I disposal,and feyycling systems) <br /> 2f3 Des gnated Facility Owner of Operator.Certification of scalp[of hazardous malar ars formed by the manifest except as rested in Item 18a ' <br /> PH d+Tyyed Nang gignature Month Day `Year <br /> EPA Form 87 - �ev.3�5y P ns aresalele. (Y 1/1 117 <br /> SIGNATEU k r TO DES t'NATIQN STATE(IF:REQUIRED: <br />