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185223-199 002198777PSc 3542388-001 <br /> Please print ord pe. A Eorm Approtted.OMB No.2050-3039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000397329 1 (877)577-2669 002198777 PSC <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ROSS STORE#0035 ROSS STORE#0035 <br /> 5756 PACIFIC AVE 5756 PACIFIC AVE <br /> STOCKTON,CA 95207(209)957-6202 STOCKTON,CA 95207 2099576202 <br /> Generator's Phone: <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7.transporter 2 Company Name r . U.S. PAID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21 at Century Environmental Management of Nevada LLC NVD980896338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760. <br /> Facility's Phone: <br /> 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10 Containers 11.lotal 12.Unit <br /> 13.Waste Codes <br /> HM and Parking Group(if any)) No. Type Quantity NJt.IVol. <br /> 1. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> 331 D006 D008 <br /> 0 X_ 1 DF 57 P <br /> � D011 13016 <br /> W <br /> Z 2. <br /> W <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Information(i)ROSSa.1-06 ERG(153)ROSS6.1.06-TOXIC LOOSEPACK <br /> 15. GENERATOR'SIOFFEROR'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.9 export shipment and I am the Primary <br /> Exporter,I ce0y that the contents ofthis,consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identifier!in 40 CFR 262.27(a)(if 1 am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator Offerors Printed/lName Signature. Month Day Year <br /> 0f- 44UT-a*Jr94- --Z-- 5 1 1 19 <br /> J 16.international Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Port of entryiext: <br /> Transporter sicgn3ture(for exports only): Date leaving U.S.: <br /> Cc 17.Transportw AcknowledgLJJ ment of Receipt of Materials <br /> Transporter t Printed/Typed Name Si a ue Month Day Year <br /> 5 1 1 119 <br /> Transporter 2 Printed/Typed Name �ature— Month DayZ Year <br /> °C 3 <br /> 18.Discrepancy. .. <br /> 1 Ba.Discrepancy Indication Space ❑ Quantity. ❑ ❑ ❑, 1 ❑ 1 <br /> Type Residue Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or.Generator) U.S.EPA ID Number <br /> J <br /> V <br /> .tdi. Facility's Phone: - <br /> w 18c.Signature bf Alternate Facility(or Generator) Mcnth Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i:e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> H141 3. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest cept as noted in Item 1 B <br /> 7FOrM790-22 <br /> Name- � Si are tvbr� Day ear <br /> EPA (Rev:12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYS7ENt <br />