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Please print or type. (Form -designed for use on elite (12 -pitch) typewriter.) Form Awroved.OMB No. 2050-0039 Er» norm arty-« trcev. o-uol rrevmous emuons are oosolete. / DE5NATE DT ILITY 7- T Atom STArE (IF ROQUIRED) 8-7,P)II-�2_12v3 CAL2007.2032 _, S41053328 1 040688311 M P➢�713i 58071317 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tramddrry Numbs' WASTE MANIFEST CAL000383.768 i 1817 5: 72E6 9 010168248 F L E 5. Generators Name and Mailing Address Generatogs !kAgAddress (d different than mailing address) Dollar General #14353 o1iar G S Tier j#14 35] c"2092751317 915 E YOSEMITE AVE 915 E YOSEMITE AVE GeneratorsPhorre:2. MANTECA CA 95336-59 2-0 I MANTECA. CA 953_6_526 6. Transporter 1 Company Name . U.S. EPA ID Number Stericvcle Specialty Wa_te Solution_ in[ I iii'jS0'u'r>r11f�+� a 7. Transporter 2 Company Name U.S. EPA ID Number 1 8. Designated Facility Name and Site Address General En v i r'o n w e n t rt i Mgt, LLC U.S. EPA ID Number 11855 White Rcc:k Road Rancho 'Cordova, CA 95742 Faciiii i,s Phone: 9163.510960Lium 4384163 ga. 9b. U.S. DOT Description (inducing Proper Shipping Name, Hazard Class, to Number, 10. Containers 11. Tatai 12. Unit 13. Waste Codes No. Type HM and Packing Group ('d any)) Quantity WtNol. X UN1950, Waste Aerosols, flammable 2.1, ERG#126 1 CF 00004 P 331 DO01 0 LU 44on RCRA hazardous waste, solid (C.Dn_umar- 1 GF 00W 3--1 r, Products) , Stan RCRA hazardous ;waste, liquid (Consumer i DF 00093 P 3.31 Pr=orr-Ict s) . 4. 14. Special Handing Instructions and Additional Information 1. 110541 (Aerosols) 2.110529(NOn-RCRA Solid Waste (CA Only-l'- Locsepack) 3.110524(Nori-RCRA Liquid Wa=te (CA Only', -- LODC-epack:) 15. rI`MRATOR'StOFFE ROR'S CERTIFICATION: 1 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 attadtad EPAAckrwwledgment 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) (d I am a small quantity generator) is true. 7toestQerot•sPnnted/Typed Name rgnaly(a Month Day Year I C r I 13 I21-711 J1f. P-- International Shipments ❑ import to U.S. ❑ Export fro�U.S. Pori of entry/exit: Z Transporter signature (for exports only): n Date leaving U.S.: W 17. TransporterAdmowledgment of Receipt of Materials _A Al �f W Transporter 1 Printed(fyped Name i Month Day Year aAnthony Mack 1 071 13 1 01 zTransporter 2 Printedffyped Name Signature Month Day Year 9 I I I I 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Residue ❑ Partial R ' char tdy ❑Type eie ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ v LL w Farf sPhone: 18c. Signature ofAltemate Fadity (or Generator) Month Day Year zI I I 0ILI 19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) In 1 � I I3 ��1 I4. 20. Designated Facility Owner or Operator. Certification of receipt of Itazatdomrs materials covepd by the manifest exW ah noted in 1101V48a T a Signature r .. ,71410iJ, 7- Er» norm arty-« trcev. o-uol rrevmous emuons are oosolete. / DE5NATE DT ILITY 7- T Atom STArE (IF ROQUIRED) 8-7,P)II-�2_12v3 CAL2007.2032 _, S41053328 1 040688311 M P➢�713i 58071317