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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 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifeal Tracking Number <br /> I` CAL000383768 CZ_T <br /> � r 011385114 FLE <br /> WASTE MANIFEST 1 8'r ,,;, 7�EE a <br /> Gererato.s Name and AtaaingAddress Generator's SiteAddress(if different than mailing address) <br /> Dollar Gener,:il #14313 <br /> @9�:7513'•i; y�7Dollar~ Gr.�tler�tl#14:��s <br /> 5 C YOSEMITE AVE 915 E YOSEMITE HVL <br /> Genarata'sPhone: MANTECA, CA 95336--5928 MANTECA. CA 95336-5' 28 <br /> o. manswer 1 olnpary Name <br /> - U.S.EPA iD Number <br /> Stet-icvcle Specialty Wa_te SuiUtion= lric ( MN5012tir7110924 <br /> 7 Transpwer 2 Company Name <br /> U,S.EPA ID Number <br /> Worldwide Recovery Systems I CAR000175422 <br /> 8.Designated Facility Name and Site Address T U in d Y e E, LLLU.S.EPA!D Number <br /> �73�I E. 13th Street <br /> Yuivat AZ 85136:=, <br /> Fac;li: %Phma- 928642893a A7_R000515924 <br /> gat 9b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, ID.Containo 9 11.Total 12,Unit <br /> HNt and Packing Group(if any)) No. Type Quantity Wt.Nol 13,Waste Codes <br /> 1.NOri i ha7At`doulc wac-t'Q. Solid 1 'onauinet Vol a . 3 1 <br /> Product 0 l <br /> 2.Non RCRA hazardous waste, 1 igt,tid (Consumer 1 UR 001 25 p ?3t <br /> � Fi1~udlir•t� 1 ' <br /> 3. <br /> 4 <br /> 14 Spacial Handing ms1 uc6ons and Add:f'onal lnformalion <br /> L. 110509(Non-RCRA solid W3St e (CA Only) <br /> 1105L:4(NGn--RCRA LjgUid Waste ICA DR10 LDoseval:0 <br /> 15, GEN BUI70R'310FfEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fury and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfplacardea,and are in an respects in proper condition for transport according to applicable international and national govemmental regulations,if export shipment and 1 am the Primary <br /> Exporter,I cartily 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 262.71(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is we. <br /> arena a rn amIgnaure omn a e'er <br /> �Inl. �c� I k y <br /> J8.International ShipmerN - l� a <br /> I- ❑Import to U.S 2 Expen fro'/U S Port ori 91try4mit <br /> Trani mler sipnnture iter experts ontvl ,-� Date leavin4 U. <br /> CE 17 Transporter Acknowledgment of Receipt of Materials / ' /f <br /> ransportEr; mtetl Typed Name azureMonth Day ser <br /> Anthony Mack (IV <br /> I / . / I � ' -,c8l �!�1� <br /> Transporter 2 Pnnte pedName Month Uay Year <br /> 18 Discrepancy 07 <br /> 18a..DiscrepancylndicaOonSpace ❑ Quan6t <br /> Y ❑Type ❑Residue ❑Partial Rejection Full Releclion <br /> Manifest Reference Number: <br /> 186.Alternate Facility(or Generate) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fabs Flione: I <br /> 180.Sgnature W Alternate Fadi (or Generator) Go Day Year <br /> Q <br /> ZI I I <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling syste s) <br /> p1 2. <br /> 3 I4 <br /> 20 Daegp wd Facility gamer or Operator:Certification of receipt of hazardous materials covered by the manifest&9Q"noted in nem 18a <br /> Month Day r. <br /> lilll�D / I1 iflit I <br /> l 2.1 ( ar <br /> .PA Form 8700.22(Rev.3-05) Previous editions are obsolete. DESIGN TED FACILITY TO DESTINATION STATE(IF RFr)I Im i <br />