|
Please mint nr tvrw IFnrm dPsinnpd fnr i mp nn plitp 11 9-nitr,.h) tvnpwritpr 1
<br />�innnnn�m
<br />Fnrm Annrnved_ OMR No. 2050-0039
<br />tl'A I-OrM b1UU-ZL tKOV. J -UJ) rlevluus eiumuns aio uuaulew.
<br />UCJIbt mi CU rAWLII r IV Ur -JI HIM IVII 0IMI G thr I\GVrVIMLU)
<br />e-7.aa_�07 f`Di P"7PA32 I 841253328, D4093MZ _. �. { __ _._ . PD091317 _ SDIO91.31-7 _,
<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number'
<br />CAL000383768
<br />2. Page 1 of 3 Emergency Response Phone
<br />1 18775772669
<br />14. Manifest Tracking Number
<br />010685552 F L E
<br />5 Generator's Name and Mailing Address Generators Site Address (if different than mailing address)
<br />Dollar General #14353 Dollar General#14353
<br />2092751377 915'E YOSEMITE AVE 915 E YOSEMITE AVE
<br />GeneratoesPhor*: MANTECA, CA- 95336-5928 I MANTECA, CA 95336-5928L,
<br />ti TrarispMer 1 Company Name U S. EPA ID Number
<br />Stericycle,Speciarlty Waste Solutions Inc I MNS000110924
<br />7 Transporter 2Company U.S. EPA ID Number
<br />re M.;3J'Z�73
<br />8. Desig ted Facility Name and Site Address U.S. EPA ID Number
<br />s p11Wj1X kkom s?5e
<br />I-1'tk/�_
<br />WS -S76-23760 mr - 95;F4
<br />Facili is Phan.-Tre3nTagaw 1 E '7"eft h�+��
<br />ga.
<br />96 U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Numher,
<br />v 10. Containers
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />Type
<br />HM
<br />and Packing Group (if any))No.
<br />Quantity
<br />Wt.Nol.
<br />X
<br />'UN1950, Waste Aerosols, flammable 2.1, ERG#126
<br />i
<br />CF..
<br />00010 •
<br />P
<br />331
<br />D001
<br />0
<br />uj
<br />X
<br />4JN1993, Waste Flammable liquids, n.o.s..
<br />1
<br />CF
<br />00010
<br />P
<br />331
<br />D001
<br />(Alcohol), 3, PG II, ERG#128
<br />X
<br />AJN3266, Waste Corrosive Liquid, Basic,
<br />1
<br />CF
<br />00014,
<br />P
<br />122
<br />D002
<br />Inorganic, N.O.S. (Sodium Hydroxide,
<br />Potassium Hydroxide) 8, PG II. ERG#154
<br />4Non RCRA hazardous waste, liquid (Consumer
<br />1
<br />DF
<br />7001 12
<br />P -
<br />331
<br />= 7
<br />Products),
<br />14. Special Handling instructions andAddibowl Information 1.110541(Aerosols) 2.110518 (Flammable Liquids - -Loose pack) 3,
<br />110515(Basic Liquids, Inorganic - Loosepack) 4.110524(Non-RCRA Liquid Waste (CA Only) -
<br />Loo s epack ),.,;
<br />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,
<br />marked and labeledlplacarded, 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 EPA Acknowledgment 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 small quantity generator) is true. _
<br />G,eenierantors/Offerors Printed/Typed Name/� re nnontn I ay Year
<br />rC{ 1 1 C t it � ��,;. f� Its---.. ... tf ! :1 ? L fA•1
<br />16. International Shipments )
<br />❑ Import to U.S. ❑Export from U.S. Port of entry/exit:
<br />Z
<br />Transporter signature (for exports onlv): Date leaving U.S.:
<br />Uj
<br />17, Transporter Acknowledgment of Receipt of Materials
<br />ransporter 1 Printed/Typed Name signature Month Day Year
<br />-Isadra Martinez—, -_ a 1..-aslf 13. air
<br />z
<br />Transporter 2 Prl ignature Month IN Year
<br />r
<br />18 Discrepancy
<br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial RejectionEl Full Re' lection
<br />Manifest Reference Number:
<br />18b, Alternate Facility (or Generator) U.S. EPA ID Number
<br />J_
<br />V
<br />Facilitv's Phone:
<br />W
<br />18c. Signature of Altemate Facility (or Generator) Month Day Year
<br />Z
<br />I
<br />N19.
<br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />0
<br />1 j,T /
<br />I2. 11�j
<br />I3. / /4P/
<br />14 /
<br />20. DesWOM FacF Owner or Operator: Certification of receipt of hazardous materials covered by 6ar4estex0epk i Itey-i9a
<br />Prini�idrrypDavne Month Daw Year
<br />tl'A I-OrM b1UU-ZL tKOV. J -UJ) rlevluus eiumuns aio uuaulew.
<br />UCJIbt mi CU rAWLII r IV Ur -JI HIM IVII 0IMI G thr I\GVrVIMLU)
<br />e-7.aa_�07 f`Di P"7PA32 I 841253328, D4093MZ _. �. { __ _._ . PD091317 _ SDIO91.31-7 _,
<br />
|