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Please print or type. (Form designed for use on elite <br />1 UNIFORM HAZARDOUS 1. Generator ID Num <br />WASTE MANIFEST I nt nhnra-7n <br />Form Approved. OMB No. 2050-003 <br />3. Emergency Response Phone 4. Manifest Tracking Num <br />A77�77P;:.Aq nn5888199 FLE <br />Lollar General #14352 Dollar Genera1#14",5. <br />20922751377 915 E YOSEMITE AVE 915 E YOSEMITE AVE <br />Generators Phone: ECR CA 95 336-5928 TE —5 <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />Sterid=cle Specialty haste Ern1utjen= Inc 14N5 11 =' <br />7. Transporter 2 Company U.S. EPA ID Number <br />c Sys 1 Pl Ef� 8676 2 t3 <br />8. Designated Fw[lity Name and Site Addres! 21st Century EMN, LLC US EPA ID Number <br />2095 Newlands Lir. Ea ---t <br />Fernley, NV 39408 <br />Facilii F's Phone: 7755752762 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 />HM and Packing Group (if any)) No Type Quantity Wt.Nol. 13. Waste Codes <br />X 1•UN1950, Waste Aerosols, flammable 2.1, ERG#126 I I CF 02203 F 1 3.311D001 <br />X 2UN1791, Waste Hypochlorite Solutions &t GC i CF 1 00009 P 122 DOQt <br />III, ERG#154 <br />3 <br />4 <br />Special Handling Instructions and Additional Information 1. 110541(Aerosols) 2.110517(Bleach, Liquid) <br />15 GENERATOR'SKffl OR'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 sjpafqnfity generator) is true, <br />n es Pn me nyt Month ay Year <br />G[ n I l �( 1 X 1 051 2512ZI <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 Printedfryped Name Month Day Year <br />N Rnthony Mack I ( 1 051 2512,31 <br />Z <br />Transporter PrintedlTyped N me ignature Month Day ear <br />16 1! 1 1 f8 <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 Yeai <br />Z 1 1 1 <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 t <br />20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />�v►�t.-; ��:�: �i �t,�,�,�:� -t �I �,�Gr.,(.�i�z.z.,r�'f 11,- I) �=� i � . <br />=PA Form 8700-22 (Rev, 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DE S'i'1,NAs ION STATE (IF RECUI =.E <br />8700--22_12v3 CAL20072032 S41053328 041103610 M FD052518 SD052518 <br />