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Please print or type. (Form desiqned for use on elite (12 -Ditch) tvoewriter.) Fnrm AnnrnvaH (IAAR Nn 9nFn-M3q ENA I-orrn 6IUU-2Z (Rev.: -Ub) Yrevious editions are obsolete. DESIGNATED FAMILITY TO DESTINATION STATE (IF REQUIRED) 8700-22_12v3 CAL20072032 541053328 041011175 M PDO11118 SD011118 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone Manifest Trackin Number WASTE MANIFEST I CAL000383768 1 8775772669 14. 010 89015 FL E 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General #14353 Dollar General#14353 2092751377 915 E YOSEMITE AVE 915 E YOSEMITE AVE Generator's Phone: MANTECA, CA 95336-5928 I MANTECA, CA 95336-5928 6. Transporter 1 Company Name U.S EPA ID Number Steric cle Specialty Waste Solutions Inc I MNSOOOII0924 7. Transporter 2 Company Name US EPA ID Number �'" c rid 3 , �' �► iC,g .� S /Jo 2 ra � J h� � L7 % �'.< 7 B. Designated Facility Name and Site Address 21st Century EMN, LLC U.S. EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facil ,'s Phone: 7755752760 I NVD930895338 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No Type o X 1. UN1993, Waste Flammable liquids, n. o. s. 1 CF 00002 P 33 . D001 0 (Alcohol), 3, PG II, ERG#128-- W X 2. UN3139, Waste Oxidizing liquid, n. o. s. 1 CF 00007 P 14 . D0011 (Hydrogen peroxide), 5.1, PG II, ERG#140 X 3- UN1950, Waste Aerosols, flammable 2. 1, ERG#12E 1 CF 00012 p 331 D001 4. 14. Special Handling Instructions and Additional Information 1.110518(Flammable Liquids — Loosepack) 2.110525(Oxidizers, Liquid — Loosepack) 3.110541(Aerosols) 15. GENERATOR'S/oFFEROR'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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. mortify that the waste minimization statement identified to 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. ts me tt 1 , Month Day ear ` f M%FnTernafionnal ��1 l % I .: '9r 1 �-. I 01I 1 it 201 F _ Shipments � LJ to U.S. ❑ Export from U.S. Port of entr➢IElfit: Z Transporter signature (for exports only): Date leaving U.S: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Pdnted/Typed Name Signature Month Day Year aI .7ohnnv Harper 1 04 111 201 Z Transporter2 Printed/Typed Name Signature x _ Month Day Year r-/r��t�-�-t 18 Discrepancy r 18a. Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V LL Facilitvs Phone: LU 18c. Signature of Alternate Facility (or Generator) Month Day Year z I I 19. Hazardous Waste Report Reeport Management Method Codes (i.e., codes for waste treatment, disposal, and r�ecyycling systems) r� 1. 4! 1 1 I2 H V ! � us tJ 1 ihazardous 3 P 1 4 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except 9s noted in Item 18a PrintedlTyped Name �` I /1 rn 0W / I Signa t�l /� /� I MoIth I ,q y, I I a ENA I-orrn 6IUU-2Z (Rev.: -Ub) Yrevious editions are obsolete. DESIGNATED FAMILITY TO DESTINATION STATE (IF REQUIRED) 8700-22_12v3 CAL20072032 541053328 041011175 M PDO11118 SD011118