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Please prin!or type.(Form designed for use on elite(12-Pitch)typewriter.)ter.) Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Plane 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000376262 11 8775772 9 01074049,8, F L E <br /> 5 Generators Varna and Mailing Address Generator's Site Address(ff diflerentthan mailing address) <br /> .Dollar General #14130 Dollar General#14130 <br /> 2097749073 4115 N EL DORADO ST 4115 N.EL DORADO ST <br /> Generators Ptane: STOCKTON, CA 95204-2104 STOCKTON • CA , 9.5204-2104. <br /> rensporter any Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc { MNSOOOI10924 <br /> 7.Transporter 2 Company Name U.S:EPA IDNumber <br /> -- <br /> C . 3,�G - I l"15 Sy <br /> c.) t�JGa. C <br /> 8-DesignaW Facility Name and Site Address KF10 LneRf LLA. U.S.EPA ID Number <br /> x 425 Isit Avenue <br /> Inglewood, CA 90301 <br /> Facile rs Phone: 3237766233 CADWB364432� , <br /> yg. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10, 11.Taal 12.Unit 13.Waste Codes <br /> HM and Packing Group(I any)) No.. f Quantity Wilvd., <br /> lurn 1 `i, rite HYPOET11orite _ o, U Sons air. – . <br /> o la VW- <br /> III, ERG#154 <br /> X,; 2UN2g1aT. Waste- Toxic solids, organic, n.o.S. 3 DF, IBIM7 P, 0@07 8027 <br /> (P-dichlorobenzene, Warfarin), 6. 1, PG II, <br /> ER6#154 <br /> 3 - <br /> . « <br /> 4. – <br /> 14.Spec d HatirlFrtg[Instructions and Addil l laformation <br /> l 1f0d+17�: L1clUltil :'2.; . B1TurLxlr�.. ll`lf}£r -;Legse k'J`; <br /> 15. GEFIERA R'$MFFEgOg'S CEFMFICAMNi i declare that tine aardent4 or IFvs consignment are fuAy and Boaiiafety desurbed atrare by ttse pngarr PWn9 nar3re,red aye rsr Rad,�rlraged'. <br /> marked and fahafed'ptK2rded,and ere in A ri peas in proper wid&n for MWixt sow'di ng b applies*tlrn okinatand rrfl&w 9veerrvnerrml regulaA -If envf dtii mAr tWid I amt wPirewy <br /> Eiporlea.f cll that the metal of this ox*wwd vadarn to the Ismra of the attadied EPA Aeknowledgrneat of Car 5ft <br /> I oll that tt(ewaa minhi ltiert sWlermt 11mbfied in 40 CFR 782.27(x)(d 1 am a hags quantity g—wilJr)or(b)(ti a gaantity generator)is fere, <br /> gSwo lvw NaWA. yor <br /> 16.Inwrlstional Impert to U.S <br /> ❑F_xpdrtfrom U.S. Portof entry? <br /> rn .Trahsporter llm(for evoits only): - Date leavrgr U,S. -. <br /> {7.7ranspartcrA&-*dgment Of Rreipto(Mallerials <br /> loiter 1 Printed/Typed Name Mrxttir my YM <br /> k AValaall <br /> Im <br /> z <br /> TftTjporw(2 Prirrtedffyped Name Mormay <br /> pq 118. <br /> i$i Discrepancy . <br /> tBa:DiscrepaniylndicatiortSpace E! QuantityQType / ❑Residue QPartialR*,%on EIRARejeetion <br /> Manif3vtRefererresNuml <br /> HE Wternafe Facility(orGenerator) U.S.EPA ID Number <br /> J_ <br /> fJ- <br /> Z Sigiftwof NalFaaAty(or Geliera Month Day Year <br /> CD <br /> 19.Hap"'W"Repaf Management Heptad Codes(ie,codes M fkzardous waste treatment;disposal,and recycling systems) <br /> C3 1. ` ' 2.TP&A +�ak <br /> I3. 414. <br /> 20. ad or Operator,Cfrtifipeti�i iptof of recehazardous materials covered by the ftdest excel g6ted n ttem 18a <br /> Na Sdgnalufe Days Year <br /> EPA Form 87 ev. )Previous editions are obsolete. DESIGNATED FACILITY'TO:DESIINATKWISTATE(IF REQUIRED) <br />