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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS J1-Generator ID Number' 2.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST t CAL000383768 1 18775772669 010685552 F L E 5 Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Dollar General #14353 Dollar General#14353 2092751377 - 915 'E YOSEMITE AVE 915 E YOSEMITE AVE GeneratoesPhone: MANTECA, CA- 95336-5928 I MANTECA, CA 95336-5928L , e Transporter 1 Company Name U S.EPA ID Number Stericycle, Specialty Waste Solutions Inc I MNS000110924 7 Transporter 2Company U.S.EPA ID Number re M.; 3J'Z�73 8.Desig ted Facility Name and Site Address U.S.EPA ID Number s pl1Wj1X kkpm ns?5' WS-S76-23760 -Rimricho + CA 95;F4 {n 1Ul ? Dp Facili !'s Pha �'/r 1 E '7"eft h�+�� 9a. 9b U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, v 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 'UN1950, Waste Aerosols, flammable 2.1, ERG#126 i CF.. 00010 • P 331 D001 0 uj X 4JN1993, Waste Flammable liquids, n. o.s.. 1 CF 00010 P 331 DI (Alcohol), 3, PG II, •ERG#128 X AJN3266, Waste Corrosive Liquid, Basic, 1 CF. 00014, P 122 D002 Inorganic, N.O.S. (Sodium Hydroxide, .Potassium Hydroxide) 8, PG II. ERG#154 4Non RCRA hazardous waste, liquid (Consumer 1 DF 00112 P 331 7 Products), 14.Special Handling instructions andAddiborlal Information 1. 110541 (Aerosols) 2.110518(Flammable Liquids - Loose pack) 3, 110515(Basic Liquids, Inorganic - Loosepack) 4. 110524(Non-RCRA Liquid Waste (CA Only) Loo s epack),.,; 15. GENERATQR'&OFFEROKS 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, marked and label"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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. 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. _ G e nera tors/Offerors Printed/Typed Name /� re Imontn I ay Year rC{ 1 1 C tail �,;.f� Its 1 gftf! :1?L11A•1' : 16.International Shipments r ❑import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports onlv): Date leaving U.S.: 17,Transporter Acknowledgment of Receipt of Materials Uj ransporter 1 Printed/Typed Name signature Month Day Year Is.><dra Martinez a L..09-�. 13 air z Tran rterignature Month ear 18 Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial RejectionEl Full Re'lection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J_ V Facilitv's Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year Z I I I N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) / 0 1 j,T/ I2. 11,s4j I3. / /4P/ 14 20.DesWOM FacF Owner or Operator:Certification of receipt of hazardous materials covered by manifestexoepk i Itey-19a PriniidrrypDaam Month Daw Year G} CS I Ild I/P-Ii-) EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) PDO 1317 _ SD091.317