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I�IN1�o11�11� <br />Pt-Else;print or tXpe., (Farm designed for use on elite (12 -pitch) typewriter.) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number 2. Page 1 of 3 <br />WASTE MANIFEST CAL000383768 1 <br />5. Generators Name and Mailing Address Ge <br />Dollar General #14353 <br />2'0927513'x:7 `_515' E YOSEMITE AVE <br />Generatots Phone: MANTECA, CA 95336-5928 <br />6. rarrsporoer ompany Name <br />Stericycle SPecialty Waste Solutions inc <br />8775772669 <br />8, Designated Facility Name and sne Acaress --1— — -1 r r 11 , r r. r , , <br />11855 White Rock Road <br />Rancho Cordova, CA 95745 <br />Facility's Phone: 9163510980 <br />9a 9b. U.S. D07 Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HU and Packing Group (if any)) <br />1 , <br />AC -0501s, t1asmanle 2.1, ERG#1 <br />X 2•UN1993, Waste Flammable liquids, n, o. s. <br />(Alcohol), 3, PG II, ERG#128 <br />3.Non RCRA hazardous waste, solid (Consumer <br />Products), <br />4 -Non RCRA hazardous waste, liquid (Consumer <br />Products), <br />Form Approved. OMB No. 2050-0039 <br />lone 4. Nlanlfast Trackin4 Number <br />1 008548865 FLE <br />different than mailing address) <br />Dollar General#14313 <br />915 E YOSEMITE AVE <br />MANTECA, CA 95336-5928 <br />US. EPA ID Number <br />I MNSOOO110924 <br />CAD98k884183 <br />10. Containers 11. Total 12. Unit 13. Waste Codes <br />No. Type Quantity Wt./Vol. <br />1 CF 00003 P 331 D001 <br />i CF 00002 P 331 D001 <br />1 1 DF 1 00094 1 P 1 331 <br />1 I DF I 00136 1 P 1 331 <br />14. Special Handling instructions and Additional Information 1.110541(Aerosols) 2. 110518(Flamnable Liquids - Loosepack) 3. <br />110529(Non-RCRA Solid Waste (CA Only) - Loosepack) 4.110524(Non-RCRA Liquid Waste (CA <br />Only) - Loosepack) <br />15. GENERATOR'SIGFFEROKS 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 EPAAdv3owledgment of g=Wt <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity 9anera6c ) (H I aN a small quan ' or' true. V <br />—+ 16. intomafi"r Shipments <br />I-- Ej Import to U.S. LJ Export from U.S. Port of entry/exit: . <br />Z Transporter signature (for exports only): Date leaving U.S.: <br />W 17. Transporter Acknowledgment of Receipt of Materials <br />6i Transporter 1 PrinledlTyped Name gna onm Day rear <br />a Jared Marciel I 1050 18 C01 <br />18 Discrepancy <br />Ise. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. AHemate Facility (or Generator) U.S. EPA ID Number <br />J <br />v <br />Facility s Phone: <br />W I K. Signature of Alternate Facility (or Generator) Month Day <br />Z I i <br />y19. ffazardaus Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling s ) <br />G 1. 2. 3. ` ' / 4. <br />HaT <br />20. na F 'ty or C rator: Certification of receipt of materials covered by manifest except as noted in It 18a <br />SKAMA <br />IP�yq�),X <br />I62 <br />EPA Formw8700- 2 (Rev. 3-05) Previous editions are obsolete.SIGNATE CIUTY TO DItINATION STATE (IF RIQU <br />