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- IIIIIIIIIIIIIIIIIull�llllllllllllll o <br /> 5200 19 002535847PSC 3735716-001 <br /> Please printlIli Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone =ng Number <br /> WASTE MANIF€ST CAL000397329 1 (877)577-2669002535847 PSC <br /> 5.Generator's 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 /> 6.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.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21st Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if an13.Waste Codes <br /> y)) <br /> No. Type Quantity Wt./Vol, <br /> 1. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> 0C 331 D006 DOW <br /> I - X 1 DF 9 P <br /> D011 D016 <br /> W 2 <br /> I � <br /> i <br /> 3. <br /> j <br /> I <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> (1)ROSS6.11.07-ERG(153)ROSS6.1-07-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.0 export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgme of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) r b)(if I am a small quantity generator)is true. <br /> Generators/offerors Printed/Typed Name S'Si nature Month Day Year <br /> 10 U,1(1 (LY tw V 10 24 19 <br /> ri 16.International Shipments <br /> j_ ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed R ed Name Sign Month Day Year <br /> a Gogr.Gracci 10 24 1 19 <br /> 4 Transporter 2 Printed/Typ ame Signaturei Month Day Year <br /> OI—C r .O r0 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity L1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> as Facility's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G L 2. 3. 4. <br /> H141 <br /> 20.D sign ted Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exceq as noted in Item 18a <br /> Print ed Name 1' Signature Month Da Year <br /> 1l <br /> EPA F -2 (Rev.12-17) Pre ous Icons are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />