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Please print r r p o type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-003 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST -AR1 00278325 i I X75 72 Aq on.98882o7FLE 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Dollar General #is3s Lr�)lai` Ct=TrF1'yl#1 - �" '092531664 1201 WEST MAIN STREET 1201 WEST MAIN STREET Generator's Phone. RTPQIVCA C15199-10P7 P T pniq Cin q`Z+A . T a 6.Transporter 1 Company Name U.S.EPA ID Number i" cVC).P 51103PC' jity IJ. t _ 1_Lit != Inc I IYI1-jci71i1i11Ai:i,4 7.Transporter 2 Company Name U.S EPA ID Number S,14c4t, S s 'T',� 1 WI6 166362,133 I Designated Facility Name and Site Address 21st' Century EMN, LLC U.S EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone: 7755752'760 1 NVD980895L38 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit HM and Packing Group(if any)) 13.Waste Codes No Type Quantity Wt./Vol. o X 1UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 CF 00017 P 331 D001i z X 2UN1791, Waste Hypochlorite Solutifins S. PG i ('F 00121l,r P 1 FIF 8fD1 III, ERG#154 �—� 3. 4- 14.Special Handling Instructions and Additional Information 1. 110541 (Aerosols) 2. 1 10517(Bleach, Liquid) I 15. G@ NERATOR'SfOFFEROR'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 EPAAcknowledgment 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. Vrawry rinme _g re Month ay Year I lir.�to lel— I mo' 1 051 .311201 International Shipments �� ❑Import to U.S. ❑Export m U.S. Port ofentry/exit: Transporter signature(for exports only): Date leavjpq l W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Month Day y Anthony Mack 1 051 30120Year1 Transpoter2P'nte yped � t� Signature v Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type e ❑Residue ❑Partial Rejection ❑Full Rejection jection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number v LL FacilltVsPhone: 1 w 18c.Signature of A@emate Facility(or Generator) Month Day Year rn 05 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling ayskwrs) G 1. 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year k + d AIM,/ P. Aj—,4, I I L 11. f i x EPA Form 8700-22(Rev 3-05) Previous edifions are obsolete. DESIGNATED FACILITY717,DESTINATION STATE(IF REr UIR.E 9700-22_12v3 CAL20072032 541053271 041109186 M PD053018 SD@53018