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X399:18 001844556PSG 3149794-001 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> t.Generator ID Number �I. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL0o0397W9 1 (877)577-2669 001 844556 PSC <br /> 8.Generator's Name and Mailing Address _ <br /> ROSS STORE#0035 Generator's Site Address(if different than mailing address)5756 PACIFIC AVE ROSS STORE#00355756 PACIFIC AVE <br /> STOCKTON,CA 95207(209)957-6202 STOCKTON,CA 95207 2099576202 <br /> Generator's Phone: <br /> 6.Transporter t mpany Name <br /> U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7.Transpo 2 Company Nave <br /> U:S.EPA ID Number <br /> 6 <br /> 8.Designated Facili y ame an Site Addre <br /> 21st Century Environmental Management of Nevada LLC U.S.EPA ID Number <br /> 2095 Newlands Dr.East, NVD980895338 <br /> Femley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13. Waste Codes <br /> No. Type Quantity WI.Nol. <br /> 1. UN1950 WASTE AEROSOLS,FLAMMABLE(EACH NOT EXCEEDING-1 L CAPACITY)2.1 <br /> 0 X .. - 331 { D001 . . <br /> 1 OF 23 P _ I <br /> LZ 2. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> X - 331 1 D006 } Done <br /> T OF 109 P <br /> D011 i D016 <br /> 3 <br /> , <br /> 4. I <br /> { <br /> r <br /> 14,$pecfal Handling Instructions and Additional information <br /> (1).ROSSAERO.05•ERG(126)AEROSOLS(2)ROSS6.1.05-ERG(163)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 classed,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 Ian the <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. Primary <br /> I certify that the waste minimization statement identified in 4D CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is hue. <br /> Gene r'sl emr's Printed yped me u <br /> $y'�J� dW n ay. Year <br /> J 1 v `Cid� 5 <br /> 16.Intemahonal Shipments 3 18 <br /> Z ❑Import to U.S. ❑Export from U.S: Port of entry/exit: <br /> - <br /> Transporter sinature for exports onW ------ <br /> Date leavin U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter.1 Printed/typed Name Signature <br /> Month ay ear <br /> a Andy_Winkler I <br /> ped Name 15 I 3 118 <br /> a' Transporter 2 Printed/tyig nature <br /> Month Day ear <br /> ~ 18.Discrepancy /�I <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type <br /> ❑Residue �Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Menrfest Reference Number: <br /> -3 U.S.EPA ID Number <br /> a <br /> � Facili 's Phone: <br /> Lu aft, of Alternate Facility(or Generator) <br /> Z Month Day Year <br /> 65 19.Hazardous Waste Report Management Method Codes(,e.,codes for hazardous waste treatment,disposal,and r <br /> wQ t. 2. ecyding systems) <br /> H141 H141 <br /> 20.Designated Facility Owner or Operator:.Certification of receipt of hazardous materials <br /> Printedffyped Name covered by the manifest except as noted in Item..18a <br /> j Signature <br /> 1 Month Day Year <br /> E A Form 8700-22(Rev.3 5) Previous editions are obsolete b <br />