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(�B��IIIIIIr►���i���I��lllll��� <br /> 002360131 PSC 3622884-001 <br /> 31 5741-1 9 Form Approved.OMB No.2050-003c5 <br /> Please print or type. <br /> t Generator ID Number, 2.Paye t of 3:Emergency Response Phone 4:Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1 (877)577-2669 002360131 PSC <br /> WASTE MANIFEST CAL000397329 <br /> 5.Generators Name and Mailing Address Generaloi s Site Address(if ddferent than mailing address) <br /> ROSS STORE#0035 <br /> ROSS STORE#0035 <br /> 5756 PACIFIC AVE <br /> 5756 PACIFIC AVE <br /> STOCKTON,CA 95207(209)957-6202 STOCKTON,CA 95207 2099576202 <br /> Generators Phone: U:S.EPA ID Number <br /> 6.Transporter t Company Name <br /> STERICYCLE SPECIALTY WASTE.SOLUTIONS INC MNS000110924 <br /> U.S.EPA ID Number <br /> 1.1 ran�,Nrler 2 Company Name /rte /O� ✓�O ?G��G7 <br /> r ` Ir� <br /> va U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address NVD980895338 <br /> 21 St Century Environmental Management of Nevada LLC <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> F acility's Phone. <br /> qa. escript <br /> 9h U S.DOT Dion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1I Total 12.Unit 13,Waste Codes <br /> Np. Type Quantity Wt.1val- <br /> t+ti+ and Packwg Group(N any)) <br /> 1. UN1950 WASTE AEROSOLS 2.2(8) - 331 DOW _ <br /> Cr - 1 DF -' 5 P ._.._.0 <br /> rJ XCC . <br /> 4 <br /> Z 2. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII. 331 . D001 <br /> C9 X <br /> 4. - <br /> !4.Special I!a?diing Instructions and Addi it 1 l Information <br /> (1)ROSSAERO-07-ERG(126)AOSSAERO-07-AEROSOLS(2)ROSSFLAMM-07-ERG(128)ROSSFLAMM•07-FLAMMABLE LOOSEPACK <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are fully andaccurately described above by the proper shipping name,and are classified,packaged, <br /> marked and iabelediplacarded,and are in all respects in proper condition for transport according to applicable-international and national governmental regulations.If export shipment and I am the Primary <br /> I xpnnei,I certify that[lie contents of this cunsignmentconform to the terms(d the attached EPA Acknowledgment of Consent. <br /> I ced'Ay that the waste rrnimization statement identified in 40 CFR 26227(a)(if 1 am a targe quantity generator)or(b)(if I am a smallquantfty generator)is true. <br /> nature. Month Day Year <br /> Geneiatur':3t)fferar's g <br /> Prated/Typed Name 6 25119 <br /> 1MtQ✓' �\� <br /> lremational Shipments <br /> import to U.S. ❑Export from U.S. Port of entryiexiC <br /> Dale leaving U.S.: <br /> Transporter signature(for exports only): <br /> cC i 7:1 inspnter Acknowledgment of Receipt of Materials <br /> Month Day Year <br /> Transporter 1 Prinledi Typed Name Signature <br /> cc 6 25 119 <br /> a Andy Winkler <br /> Month tray Year <br /> Signature <br /> Z TranspO ler 2 Printed/Typed Name <br /> 18_Dir re panr:y <br /> 18a Discrepancy Indication Space t Quantity F,r yp ❑Residue O Partial Rejection �Full Rejection <br /> L_I <br /> Manifest Reference Number: . <br /> ? 18b.Altpmate Facility(or Genu ator) U.S.EPA ID Number <br /> h— <br /> ;J <br /> uu-- Facility's Phone <br /> Month Day ,Year <br /> O t&..S'@iahrre o!Aflemate Frdlity{or Generator) <br /> 19 Hazardous Waste Re(c)d Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems). <br /> wc� 1 T <br /> . 9. 4. <br /> H141 1-1141 . <br /> 20.Designated F,1:Ally Owner or Operator.Certification of receipt of hazardous materials covered by the manifes except a ed in Item 18a Month Day Year <br /> Printed! ?e , ?e Sign re Q <br /> FPA Form 8100-22(Rev.12-17) Pievious edifions are obsolete. V DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />