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Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No 2050-0039 <br /> r UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL@00376262 f 1 18775772669 I 012120207 FLE <br /> 5. ralor's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #14130 Dollar General#14130 <br /> 2097749073 4115 N EL DORADO ST 4115 N EL DORADO ST <br /> Generator's Phone: STOCKTON, CA 95204-2104 STOCKTON. CA95204-21@4 <br /> t Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc I MNS@@0110924 <br /> T i ransporter 2 Company Name U.S.EPA ID Number <br /> /`J40e / 1 �/p4 4p <br /> B.D ignated Facility Name and Site Address 21st Century EMN, LLC U.S EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facilit}isPhone: 7755752760 I NVD980895338 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> X 1UN1791, Waste Hypochlorite Solutions 8, PG 1 CF 00031 P 12E D002 <br /> III, ERG#154 <br /> W <br /> LU <br /> Z X 2UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 BA @@0@1 P 331 D81011 <br /> c� <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information 1. 110517(B 1 e ach, Liquid) 2.PKG—DF:110541 (Aerosols) <br /> 15. GEN ERATOR'SIOFFEROR'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, <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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)crib)(if I a mall quantity generator)is true. <br /> Gen M e n g� on ay Year <br /> 41 Ir_ 1( I 1101 161201 <br /> In em ti al Ihipments <br /> 11 z Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/typed Nameig Month ay Year <br /> a Jeff Hamilton 1 101 16120111 <br /> z Transporter 2 Printedfryped Name Sg!>]thre Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ QuantityType ❑ ❑ I ❑Full Rejection <br /> ❑T e Residue Partial Rejection <br /> Manifest Reference Number. <br /> 181b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> I Facility's Phone: 1 <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> C3 �``�\ 2 `t"11 I-1 ' I3. I <br /> 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted m Item 18a 1 CIC <br /> Printed/Typed Name Signature Month Day Year <br /> (--7 1 P, x,6-fz- �K- i C��- �l� I 1 fi�i►--6 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 8700-2212v3 CAL28072032 541053295 041225683 M PD101618 9DIO1618 <br />