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Please print or type.(Form designed for use on elite(12-pitch)typewritesIN11111III11I1) Form Approved.OMB No,250-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3.Emergency Response Phone 4.Manifest TraekIng Number WASTE MANIFEST I CARS00278325 11 8775772669 011388808 F L E 5 Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Dollar General #13357 Dollar General#13357 2092531664 1201 WEST MAIN STREET 1201 WEST MAIN STREET Generators Phone: RIPON, CA 95366-3027 RIPON, CA 95366-3027 6.Transporter 1 Company Name U.S.EPA ID Number Steric cle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number Ti 4 Wo e-h- ti 40 47 4`I ilrJl9ir 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Fad is Phone: 7755752760 I NVD980895338 98. 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, W.Containers 11 Total 12 Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes X 1-UN1791, Waste Hypochlorite Solutions 8, PG 1 CF 00033 P 12 D002 III, ERG#154 zz„ X 2•UN3264, Waste Corrosive Liquid, Acidic, 1 CF 00010 P 791 D002 Inorganic, N.O.S. (Hydrochloric Acid, Phos horic Acid). S. PG II. ERG#154 X 3-UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 HA 00015 P 331 D001 4 14.Special Handling Instructions and Additional Information 1. 110517(Bleach, Liquid) 2. 110514(Acidic Liquids, Inorganic — Loosepack) 3.PKG—DF:110541(Aerosols) 15. GENERAT0W5K PPHROR'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 EPA Acknowledgment 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)(if I am a small quantity generator)is true. ame / erature Month ay Year �-► �)Civ,�,?.G F 16.International Shipments ❑Import to U.S. ❑Export fro Port of entry/exit: Z Transporter siqnature(for exports onlv): Date leavina U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name rg Month Day Year a Jeff Hamilton 1 1 091 0112011 U) Month Day Year Tran 2 P inledrTyped Name C- 18. v'Priv I I Discrepancy l 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number J v LL Facility's Phone: LQ 18c.Signature of Alternate Facility(or Generator) Month Day Year z I i I N19.Hazardous Waste �� ` Report M(anagement Method Codes(i.e.,codes for hazardous /waste treatment,disposal,and recycling systems) ` ` LU G 1 trF�`�1 2 �4`4,\ 3 � f q 1 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrinSignature Monyl D y Yea tedlf y / "'� EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. i f DESIGNATED FACILITY" EST ATIQN STA =IF REQUIRED) 8700-2212v3 CAL20072032 S411053271 041172948 M PD090118 SD090118