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r?p N _ TrIs <br />Please print of type. (Form designed for use on elite (12-oitch)'tvoewriter.) rrrnc utrrtaazaa t a Form Aooroved. OMA No 2i n-ffialq <br />crn rurm BrUU-LL tit J-Uj) Previous editions are obsolete. ,IESIGNATED FACILK0 DESTINATION STATE OF REQUIRED) <br />UNIFORM HAZARDOUS <br />� 1 �emQ�IDt AN'z� Z7�A <br />2. Page t of <br />I <br />3. Emergency Response Phone <br />I <br />� 4 �008664889 <br />WASTE MANIFEST <br />F L E <br />5. Generators Name and Mailing Address Generator's 50e Address (d different than mailing address) <br />Dollar General#14353 <br />M2751377 .: .. 9,15,E YOSEMITE _ AVE <br />Gens Phone: kwFen, CLl 9533E,-59 g - • : I <br />6. Transporter 1 Company Name US, EPA ID Number <br />Stericvcle Specialty Waste Solutions Inc MPS,. 1109x^4 <br />7. renW 2 Company Name _ U.S. EPA ID Number <br />rif C4rr.`r o{ 04, 7 <br />8. Designated FacilityName and'SiteAdd " General Environflentual Mgt, LLC U.S.EPAIDNumber <br />11855 White Rock Road <br />Rancho Cordova, CA 95742 <br />f <br />Facilily s Phone: 9153510980 I CAD9 884 83 <br />9a, <br />9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />1 t. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />H_M <br />and Packing Group (if any)} <br />Quantity <br />WtNd. <br />',Non;•RCRA hazardous Wastes solid (Consumer <br />2 <br />DF <br />09EN <br />P <br />33 <br />a <br />.Pr'ciciuct s) , <br />Z <br />Z <br />ur <br />3 <br />4. <br />•Di'y <br />14 Special Handling Instructions and Additional Information 1. 110529(Non—RCRA Solid, Waste •(CA Only) — Loosepack) <br />15. GENERATOR`SIOFFEROR'S CERTIFICATION: I hereby declare that the contents Of this c0n0gn0ent are fully and accurately described attune by the proper shipping name, and are dassified, padtaged, <br />marked and Iabe(edlptacarded, and are in a0 respects in proper condition for transport according to applicable intematimal and national governmental regulations. If export fpment and I am the Primary <br />Exporter. I certify that the contents of this consignment conform to the terms of the attached EPAAdmox iedgment of Consent <br />I certify that the waste minirrkation statement identified in 40 CFR 262.27(x) (d f am a large quantity generator) Or (b) ('d I am a stSa4uartllty generator) is true. <br />S FMXVTYPW Name tignawre dt Day Year <br />rf sh f}%� `fi.._� .,._ ,. _ .� �. 091, .231 2tg1 <br />1 <br />16 1 Shpments <br />❑ Import tO U.s. ElExport 6om U.S. Part of entrylexit: <br />— <br />T bre only): Date leaving U.S.: <br />17. Transporlerr AdmoM odgment of Receipt of Materials <br />Transporter 1 Printedlfyped Name m Month Day Year <br />$ <br />�ristopher Aleanzas 091 2.312011 <br />Transporter 2 PrintedlTyped Namegnatu .a Month Uay Year <br />kk ff <br />16. Discrepancy <br />18a. Discrepancy Indication Space F� Quantity ❑Type ❑Residue El Partial Rejection Full Rejec3ion <br />Manifest Reference Number. <br />I Bb. Alternate Facility (or Generator) r U.S. EPA ID Number <br />U <br />Faci tys Plane: <br />w <br />16c. Signature of Altemate Facility (or Generator) + . Month Day Year <br />2 <br />I I <br />rn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treaUtrent, disposal, and recycling systems) <br />ca <br />1- <br />2. <br />3. <br />14. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by ft manifest except as rated in Item 18a <br />rnhtedlTyped nns Sgni turatt 10011th Day Year <br />iI? r f 9 SID <br />crn rurm BrUU-LL tit J-Uj) Previous editions are obsolete. ,IESIGNATED FACILK0 DESTINATION STATE OF REQUIRED) <br />