Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0035 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST r,gL0003A37&J9 I I A77977P- 9 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Dollar Gener--yl #14352 Lollar- Genera1#14_5• <br /> 20922751377 915 E YOSEMITE AVE 915 E YOSEMITE AVE <br /> Generators Phone: ECR CA 99336-5928 MANTE95-1-%A--iqPA <br /> 6-Transporter 1 Company Name U.S.EPA ID Number <br /> Sterid=cle Saecialty i 3ste Ec.1utjer= Inr 14N5 ii =' <br /> 7.Transporter 2 Company U.S.EPA ID Number <br /> c Sys V6_4's I t,,!Ef� M 361 0 <br /> 8.Designated ad ty Name and Site Addres! 21st Century EMN, LLC US EPA ID Number <br /> 2095 Newlands Lir. Ea---t <br /> Fernley, NV 39408 <br /> Facilil 's Phone: 7755752760 NVD980695.3.32 <br /> ga. 9b.U.S,DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12,Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> X 1•UN1950, Waste Aerosols, flammable 2. 1, ERG#126 I CF 02203 P 331 Doe <br /> 0 <br /> zz„ X 2UN1791. Waste Hypochlorite Solutions 8. GC i CF 00009 P 122 D00 <br /> C' III, ERG#154 <br /> 3 <br /> 4 <br /> 14 Special Handling Instructions and Additional Information 1. 110541(Aerosols) 2. 110517(Bleach, Liquid) <br /> 15 GENERATOWSIOFFEROR'S 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 EPAAcknowledgment 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 s qi nfity generator)is true, <br /> n es Pn menyontn Day Year . <br /> 051 25 12ZIP <br /> -J 1 .International Shipments // <br /> Z ❑Import to U S, El Export k/.U.S. Port of en lelrjR: <br /> Transporter signature(for exports only): / \ gate lea ng p�S,: <br /> w 17.Transporter Acknowledgment of Receipt of Materials 7 71 ` 71 <br /> Transporter 1 Printed/Typed Name Month Day Year <br /> N Anthony Mack 1 1 051 251 '01 <br /> Z <br /> Transporter Printed/Typed N Signature Month Day Year <br /> 16 1 !1 1/6 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: 1 <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z 1 1 I <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2 3. 4. <br /> f4 i L- I t 7 <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrryped Name Signature Month Day Year <br /> �v►�t.-;��:�: �i�t,�,�,�:� -t �I �,�Gr.,(.�i�z.z.,r�'f 11,- I )�=�i �. <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. ;'DESIGNATED FACILITY TO DESTINA"il ION STATE(IF RE(:'1U1=.F-11 <br /> 8700--22_12v3 CAL20072032 S41053328 041103610 M PD052518 SD052518 <br />