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'2U BREMNER <br /> -P se prim or type..f.Fotm des[gned foruse on elite 12 ch 001954737PSC 3271744-001 <br /> ( i tyriter_) <br /> F <br /> OR IHA,IAltQOUS t Generator ID Humber Form Approved.Mt-No-2D5fl-0Q39 <br /> 2.Page 1 of 3 Emergency Response Phone tNanitesf Tracking amber <br /> WASTE tl ahl�Esr cAL�o0351o7i 1 (877)s77-2sss ODS 954737 PSC <br /> eratofs NamMattinAddress- <br /> LOTSSTt}RES _ ,arerators SiteAdd14 differuntfltan rrPHlL1lP Fit],Ili fN:DEIVA F�FiARtJ BIG LOTS#4617 <br /> COtlltl RO3 ,QH 43228(614)275.4614 1321 WEST YOSEMITE AVENUE <br /> Generaters Thane: _ MANTECA,CA 55337 2032393864 <br /> Transpaaer f ompsrry me :. . <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC U.S.EPA Ip Number <br /> Or' er2Co MNSOW110924 <br /> YN <br /> U.S.LPA ID Number <br /> KoC � <br /> &.Designated Facil:fy ame and Site Address <br /> 21 st Century Environmental Management Of.Nevada LLC US EPA to number <br /> 2095 Newlands Dr.East, NVD98t1895338 <br /> Fernley NV 85408 -(775)575-2760 <br /> Facilily's'phone: <br /> 9a. 9b.U.S.DOT description(irdf ding Propaf Shipping Nance,Hazard Bass,ip Number, <br /> fiM and Paclarrg Group(it-01 it).Containers 11.Total 12.Unit <br /> 1. U i95o W,ps rE AERR50�5 2.1 <br /> No. Type Quantity 13 r1fo1 13.. Waste C*des <br /> rY <br /> X 331 -0001 _r _ <br /> i <br /> OF 10 P -- - <br /> Z 1. UN2910 WASTE TOXIC,Li{tUf05 ORGANIC, - - <br /> nr PNC,01.0.8-(2,4.0}6.1 PGIr i <br /> x, 331 ` 0018 <br /> i DF 64 P t <br /> 3 i <br /> a <br /> ) <br /> 14.Speciaf liandling JnSlnrcuonsfor <br /> .and AMM Inma(ion <br /> (1)sLAEROSoiS 04-ERG(126)OLAEROSOLS-04- <br /> AEROSOLS-• <br /> t23BL70S1C-D3 :R i53 BLTOXiC- 3-TaXIC tldU105 LEOSEPAE( - <br /> 15. GERERATOWStOFFItROR'S CERTIFICAMN: l trerebydeclare.M the adr tt nts of this consi <br /> marked and lahetedlpiacarded;-and are in all res t in gnment ace UtY and amurafely described above by the proper shipping name,and are classifmp,packagad, <br /> pec ptaper Gond ion for transporl according to applicable imematimal and Rational goveramemal regulations.if export shipment and lam the Primary <br /> Exporter,Icertifythattarecontentsof.this oasigrmlentowkrmtotheterms6fftattachedEPAAcknowledgmentofConsent. <br /> I cerfiiy that Thewasle rninsmiratiDn statement idesttrfied in 4b CFR 26227(a)jel am a large quantAy )or(b}[41 an a small quan enerator)is true <br /> torsi rors. nted ypedName <br /> ear <br /> -1 16:lnternalional Shiprnenfs _ <br /> � 17 i8 <br /> 2 ❑ <br /> Import,10.U - ElE U.S. Port of entry? ' <br /> Trans rter signature for-pods Gate Ieavi <br /> 17.Transpo arAeknowledgnwtofRer.>r$cfklaheaals <br /> f'— Traruporier.t PfpntedffyW Name <br /> >gn re ear <br /> a Darryl Johnson <br /> 7rarra r 2 Nniedffypl <br /> 16.Discrepancy <br /> 1Ba.Discrepancy Indication Space <br /> ❑.f�uard ty Type Q Residue. ❑Pap a1 Rejection Q Fuf Rejection. <br /> F>' 1 r Alternate 7B1 11-tr(or Generator} Manks(Reference(lumber. <br /> U.S.EPA ID Number <br /> U <br /> 'i <br /> facility's Phone: <br /> LU 1$c_SignatureotAnemateFxrtify(or Generaw) <br /> d Month Day Yew <br /> Z <br /> V5 19.Hsa;artfous Wwe'Report iblatsagement WOhod Codes(i.e.r codes far hawdooa Naste <br /> treatrmnt,disposal,and rx%[irrg systems) <br /> 1 <br /> H141 4, <br /> H141 <br /> 20,Designated Faciktr Owner oro o4gt CeAfinahon of recetpl of hazardous ma lots oDwed by ltte maltlesl except as noted in Item 18a <br /> Prince - <br /> Day <br /> r p� <br />