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t. IF 4. I _ IIIIIIIIIII III IIIIIIIIIIIII I I VIII III � V_ T r 1 1 <br /> 402350-19 0024311OOPSC 3671373-001 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Paye I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CALOOW97329 1 (877)577-2669 002431100 PSC <br /> 5 Gencmlo�s Name aid r0mling Address Gener<alor's 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 /> Gene:atoc' <br /> o liarspor cr 1 Name U.S.FPA ID Numher <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 1 Tr a;porter 2 Company Name e-7- " U.S.EPA ID Number <br /> 3 Designatod Facility Name and Site Address U.S.FPA ID Number <br /> 219t Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Farility's Phone: <br /> g;1, 9h.US.DOT Description(Inc ading Proper Sli ring Name,Ha70rd Class-ID Number, 10.Containers 11 Tota! 12,Unit <br /> M and Packing Group(If any)) No. Type Quantity WI./Vol:E: D006 <br /> 1. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> D008 <br /> 0X1 DF 122 Pi <br /> ua <br /> Z d <br /> { <br /> 4. <br /> d <br /> i <br /> 3 <br /> 14-Special Handling Instructions and Additions!Information <br /> (1)ROSS6.147-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK <br /> i <br /> i <br /> I-. GENERATOR'S(OFFEROR•S CERTIFICATION`. I hereby declare that the cor lents of Ifi s consig_menl are fully and accurately desrrbed above by[lie proper shipping name and afe class I ed,n<¢:k ;eo <br /> marked and tabeied/placarded,and arta in ail respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exportef.I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large griant0.y generator)or(b)(if I am a small quantity generator.is true. <br /> Genera r;;'Offer.irs Prinle(hItyped!N100, Sign r Monti Day year <br /> r�� 1' 8 7 19 <br /> i 16.Intem<Ronal Shipmi tits <br /> ~ ❑Import i1 .S. ❑Export from U.S. poll of(Al/exp <br /> Z Transporter signature(for exports only): Date leay S <br /> w <br /> II f!inspndcr Acknowiedgment of Receipt of Materials <br /> franspoder.1 NiNedtTyped Name Signature Month Daycc <br /> Year <br /> a Chris Gilliam 8 7 19 <br /> ZIran spoder 2 PrintedlTyppd N;ime % Signator. MAonth Day Year <br /> 1E.Discrepancy <br /> 18a.Discrepancy Indication Space [ i <br /> Quantity ❑Type El Residue Q Partial Rejection [JI il Reieclion <br /> Manifest Reference Number: <br /> 1 Sb.Alternate Facility(cr Generator) U:S.EPA ID Number <br /> U - <br /> I FaeiiitysPhone <br /> Q <br /> I&,Signature of Alternate Facility(or Generator) Month Day 'real <br /> Z <br /> 19 1 lalaro"oF,t,0e Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ I 2 3: 4. <br /> � H141 <br /> I OesignM d Facii i:Owner or Operator:Certification or recei cf hazardous materials covered by the manifest 6xceq as need In Item I&I <br /> Pr llied/Typed N, rte Signature Mr Da^ t:? r <br /> LPA f o!ni 8700-22(R .12-17) Previous editions are obsolete. ( ) , D FACILITY TO EPA°s e-MA (FES,SYS-€/�El]M <br />