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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) � Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS +1 Generator ID Number 12.Page 1 of 13.Emergency Response Phone I4.Mani <br /> fest <br /> 10 7 um 0 4 9 9 F L E <br /> WASTE MANIFEST I CAL000376262 1 8775772669 <br /> 7—Generators 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. CA 95204-2104 <br /> 6.r•8nsporler 1 Company Name U.S.EPA ID Number <br /> Steric cle Soecialtv Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2 Company Name G, U.S. <br /> EPA ID Number t p a <br /> 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facilil,'s Phone:7755752760 NVD980895338 <br /> ga, 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)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> WIST.0 Herosols, rlaeeaale 2. 1, KUWle—b 1 CF X88 P 3311 D001 <br /> O <br /> tz X 2UN , Waste Flammable liquids, n. o.s. i CF 00022 P 331 D001 <br /> (Alcohol), 3, PG II, ERG#128 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 110541(Aerosols) 2. 110518(Flaeeable Liquids — Loosepack) <br /> 15. GENERATOWSWFEROR'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 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 <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 h40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I amt small gyantity generator)is true. <br /> GanengaeWOffemes Prin Name na Month tray Year <br /> Ch IS 14 1 081 09120111 <br /> .j 16.international Shifnents <br /> ll'— Import to .S. ❑Export from U.S. Port of entry/exit: __ _. _ <br /> E Transporter siqnature(for exports oniv): Date leavinq U.S.: <br /> IX W 17 Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0M Miguel Ayala ` 08l 09120111 <br /> Z Transporter 2 Printed/Typed Name Signature Month Day Yeaar <br /> 18 Discrepancy ` <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facilitv's Phone: 1 <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z I I I <br /> 0 19.Ha <br /> zardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> � ' i t.( I2 � 13 µl ) � 4. <br /> 20�aigrteted�cility Owner pr rator:Certification of receipt of hazardous materials covered by the manifest icept as noted in RA 18a ,. <br /> pn r �u 4,Of 15"T —';�K AM" 17 1 A I Pi <br /> EPA Form 8700-22(Rev.3-05) Prev' us editions are obsolete. DESIG D FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 8700-2212Y3 CAL20072032 S41053295 041174737 M PD080918 0080918 <br />