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(0) , 11111111111IN111111P P2 <br /> 632622-17 001634839PSC 2877928-001 <br /> Nease print or type_(Form designed for use on elle(12-pitch)typewriter.) Farm ApW yved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1'liererdter 10 Number =2 (8;77) <br /> nq Response i'rrune 4.Man'rfeei Tacking Number <br /> WASTE MANIFEST CAL000391074 577-2669 001634839 PSC <br /> 5.Generator's Name and Mailing Address Generators SdeAddcess{irdllerent than ma[hng a0rss} <br /> BEG LOTS STOKES BIG LOTS#4106 <br /> 300 PH(LUP RD,ATTN,-DENA FERARU 380 S CHEROKEE LANE <br /> COLUMBUS,OH 43228(614)278.2705 LODE,CA 95240 2093686859 <br /> Genera€oi s Phone7 <br /> ransporter f Company Name U.S.E3 A IQ Nurtrber <br /> STE:RICYCLE SPECIALTY WASTE SOLUTIONS INC MNSDO0110924 <br /> 7.Transport y Name �'1 U.S.EP f0 Number <br /> S.Designs aa1$y Name arrd She Address a S.EPA 1D Number bei <br /> 21st Century Environmental Management of Nevada LLC S.EPA ID Num338 <br /> 2095 Newlands Car.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Fara)l's Fbone: <br /> 9a. %.US.007 Dew4bon(wJuding Proper Shipping Name,Hazard Class.ID Number. 1fl.Containers 11.TOIaI €2.Unit <br /> and Pardting Group(#any)) No. Type QuaRRY WLPbI, 13. Wasle Codes <br /> p <br /> 2. [ <br /> W x 9F'«-.11—Ei99r. <br /> ;t„��u:ne.:_rerwcrr_��y�S143:LfOLllh,i7AJrlc,'""' -��-' <br /> t <br /> R12111 7(kj <br /> -�ovr-�•-(erg-.�.�y:: <br /> 14,Special Hardlieg Instructions and Addilioul Infomratlon <br /> 14)Ell Ar <br /> 15. PENERATOR'SIOFFEROR'S CERYIFICATioti:i herehy declare Oal thecumlenls of oris consignment are fuly and accurately described above by the proper stopping name,and are'dassiYed,'packaged, <br /> mar€ged and laheledlplacarded.and are in all mspecis in proper condition for transport ar_cording to applicable intematimal and nations€gov i-axpmt shipnml and I am the Primary <br /> E der,t ceffify lhattherAmfenrs oFth wusgnmea€CoMum to the terms offte ahashed EPAAckru wkdgmer4 sent. <br /> I ce ry that the waste minimization statumsnt identified ie 4Q CFR 262.27fa)(ill am a large quanfhy g ralor) (b} lam a sinal€ amity 9 uue, <br /> 1-ieneraWWeroft RMWITyped N Walh Uay Yda( <br /> . OternaNcnal Ship n s <br /> ❑)w'1 to us ❑Export I.-as POd 0 il' <br /> Tians ortusi nature re flsonl le-avin <br /> 17.Transporter Aclm4wtedgmew Of Receipt ai materials <br /> Transpodei 1 PrinIedlTyped Namena re <br /> 44 4 44 1 ay ear <br /> Darryl Johnson - I 8 21 17 <br /> QTransporter 2 Prnrtadlf gnature o ay Year <br /> fe t <br /> 18.Discrepancy <br /> iiia.Discrepancy Indic4on Space 1J Ouanlih ❑Type ❑ZeSidc ❑PanialReceFul2ee6On <br /> Manifest Ralereme Number. <br /> t$b.Aitemate Facaity(or Generator) U-5.EPA 10 Number <br /> Q <br /> u.. Facdil's Phow <br /> Ujt$c.SignatureofAltemateFaciRly{DrGoneraiOeJ IiA -1 pay Year <br /> Q <br /> 19_Hazardous Waste Repntf Management Whod Codes(i.e,.codes for hazardous waste treatment,disposal and recycling syslems) <br /> i.. H141 2. <br /> 11122 3 11141 a H141 <br /> 20.Designaled Fadtity N-ner or Opora€or:Gedif cat on of receipt of hazardous mate;ars covered by fi a manifest except as nosed in Item lea <br /> Pfiow-niped Name <br /> Sgnature h4onlrr Yea[ <br /> IPA Form 8700-22'(Rev.3-05) Previous editions areo5sotete. f <br />