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' .: T � ., `�{irl�ll�f1�11�iIfN1l11�11I I IE I111�1 . <br /> F1ea�e Print or type-{Form designed for Ise on erne1z 00�848885PSG ` 315778-001 <br /> ( pitch)typewriter.} , <br /> U NfFORM HAZARDOUS I.Generator ID Numbo, 2 Page 1 at 3 Eme f=orm Apprnyed.OW No.2050-0039. <br /> WASTE MANIFEST : CAL000391069 r Response anone 4.Alanifest Tracking NI-ber <br /> 5-GeneiaWs,Nfame and Mailing Address 2 (877)577-2669 - <br /> 001848885 PSC <br /> BIG LOTS STORES Generators 5 to Address 1if different than mai4ing address} <br /> 300 P#ifLLIP RD,ATTN:DENA FERARU Bld LOTS#4105 <br /> COLUMBUS,ON 43228(614)278=4614 8061 WEST LANE <br /> Generator's Phone: STOCKTON,CA 95216 2094732823 <br /> ranspprter 1 any ame <br /> STFRICYCLE SPECIALTY WASTE SOLUTfONS INC 4 U.S.EPA iD Nwnher <br /> 1.Tr spvrter 2 Company Name MIMWI 10924 <br /> - « U.S.EPA ID Nurrfber <br /> 8.Designed F WY ame arrd Sile dress <br /> 21 st C--ntury Environmental Management of Nevada LLC S.EPA 10 Number <br /> 2095 Newlands Dr.East, NVD980SM340 <br /> Femley NV 89408 (77.5)575-2760 <br /> Fac4ity's Phone: <br /> 9a. !b.U.S-DOT Description(indudhrg Proper Shipping None,lfazard Class.ID Number, <br /> HM and tacking Group(i any)J 10.Containers 11.Tota 12.Ung <br /> No Type Quanfity .Alrt.Nal, 13. Wasle Codes <br /> - A _ f <br /> 2. ON195a WASTE AEROSAL3 2.1 t <br /> ul <br /> '- e- <br /> 3$1 } DOD1 F <br /> 1 UAI 13 <br /> 3. t1F11991 w4sTE FLAMMABLE UOLMS,"z.(1(Efi EM.BIESEL)3 Pot <br /> ,X ' <br /> = .s31.. Doa1- ; Woos <br /> 1 DF 17 t . <br /> 4. v"1791 WA51 E HY OR1TE SCLr1l1ONS 8 PGIt <br /> 0007 Dote t» <br /> 122 z Dr1O2 <br /> OF 14 <br /> f <br /> - 14:SpeCia}NandtnsglnstrudfonsantlAdditionallnfomialmn - <br /> -"GTBL&AC*W,E�(J"BLEACH (2)BLAEROSDL�� 04-ERG(126)BLgERO$pL$p4•AERp3p(r(3)BLM AML[Q-p3-ERG(128)FLAMMABLE LIQUIDSra (A] <br /> - <br /> 15- GEtJgiATOR'Sr9pFFERpR 5 CERTIFICATION! ]hereby declare thatthe contents of this cossfgnmenl are fully and accurately described above the <br /> mOftd and labeledlplacarded,ad are in respects in respein Proper Gonditlorl iDriranspoR aCcorrting 10 applicable international and national v �I proper shipping name,and are claSsifred.packed, <br /> ExP"ler,k cell fy Thal the Conients of this consipnrnent conform t the terms of the alta tied EPAAcknOwlsdgmenl of Consent, regulafirrns ffexp0rl shipment and 1 am the Primary- <br /> _- - t certify that the waste 61iMLrAi0n Slatement identified in QU CFR 262.27(x)(if I am a targe quantify ger>era`oar or dI am a small qua4ti <br /> ner73. C)d s_ y blame 1 t ]f ty generator?s tae. <br /> ren m n <br /> Year <br /> 16.1nternafion�Sflitsrtenlst--� I�CZSI_ ti 5 3 $ <br /> F LJirriparttoUs: ❑Eaglortirom.u5. PvnOfentrytexti <br /> -Transe2ders'nature fore its Orr <br /> Uj 17,Transpo rA*owlerlgment of Rooeipl of Maenafs Date feaVinq U.S.: <br /> Transporief Printedlryped tJarre, <br /> IY Andy hrMelr na re om - <br /> rranspnr[ 2]'RntedlTyped Nasrre 3 .18 <br /> ahsre l onth ay Y <br /> 18.I)iscretsancy <br /> 1Ba-VixiepancyIndicationspace: .l _t ouarrtily ❑Type ❑Residue <br /> ❑Part alf2ejeclipn ❑Ful Rejection <br /> L18b.Allernale.Facilly(or Generator) 6Aanifesr Rete ence Numbe <br /> U.S EPA ID Nufnber <br /> �- <br /> F&*Vs Phune: <br /> W IOU. ignad0re0f,Wt MMfaeft(or <br /> Cierl@star} Day Year <br /> mow, <br /> 19.Hazardous Waste Report rufanagement WtF W Codes{i.e.,codes fur hazardous axle healment.disposal;and recyitir:g'systems) <br /> Uj <br /> . i. 2. <br /> H141 H141 a_ H070 <br /> 26.Designated Facility Cwaer or Operator CeriftiGatia 1 of rece pt of hazardous imWrids cowfed by the manifest except as rusted iu Item 1lta <br /> PrinledlTyped Nam_e. <br /> ..�— Signalxe - rrAmth <br /> ..�. Day Yt'ar <br /> E _ Form 87 22(Rev,3-05) Previews editim.are obsolete. <br />