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�— <br /> --------� �. _ � IIIIIIIIIIIIIIfIIIIIININIIIIIIIIIII �- - <br /> ------------ <br /> 584378-:19 002572163PSc t 3771659-001 <br /> Please orint or typeForm Approved.OMB No.2060'0039 <br /> UNIFORM HAZARDOUS 1 Generator lD Number 2.paye 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> tMAStE MANIFEST CAL000397329 1 (877)577-2669 0025721 63 PSC <br /> 5,Generators Name and Mailinn Address Generator's Site Address(if different than mailingaddress) <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 /> Generators Phone <br /> $,Transporter t Company Name 1J.5 EPAID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS0001.10924 <br /> TAransporter 2 Company Name U.S EPAID Number <br /> Jet <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 /> G a(dhly s.Photle.; _ <br /> ga 9b US.DOT Description(includnta Proper Shipping Name Hazard Class.ID Number; 10.Containers 11:total 12 Unif 13 Waste Codes <br /> NM 'and Packing Group(if any)) No. type Quantity Wt.IVol. <br /> 1. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII 331 D006 D008 <br /> 1 OF - 73 P _F._LU <br /> _. <br /> Doll D016 <br /> LU <br /> Z 2_ 1 <br /> -------- <br /> 4 _. __d <br /> i4 Speciattiandling Instructions and Additional Information <br /> (1)ROSS6i1.07-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK <br /> 1;a nment are fuly and accurately described above by the propers <br /> GENERATOR'SlOFFEROR'SCERTIFICATION:I horehydeclare that the contents of this consig 'hipping name:and are classified,packaged <br /> mental regulations.If export shipment and I am the Primary <br /> marked and lahelediplacarded,and are in all respects in proper condition for transport according 10 applicable internalionatand national govern <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. , <br /> ce jib t khe waste minimization statement identified it.40 CFR 26227(a)(if I am a targe quantity generator)or(b)(if I am a smallquantdy generator)is true. <br /> Gent rato's roc's Prinledlfype Name <br /> Signature Month Day Year <br /> 11 1 12 1 19 <br /> J 16 Intel7tof1bi Shipments ❑Import to U.S. ❑Export from US Port of entry/exit <br /> z Tfanslmrte+stgnature(forexports onlyp Dale leaving US <br /> ca 1 i 1 ransporterAcknowledgment of Receipt of Materials <br /> KTransporter)Printed/Ty d Name ( Signature Month Day Yr:ar <br /> cc C 11 12 19 <br /> a- � - \ <br /> z Transporter 2 PnlotedrFy Slanalure Monih Day- year <br /> 1 'w 1� <br /> 18.Discrepancy <br /> 18aQuantity.Discrepancy Indication Space ❑fy t ❑Residue ❑Padial Rejection' ❑full Rejer,Gon <br /> ❑ I <br /> Manifest Reference Number: <br /> U S EPA ID Number <br /> H- <br /> I Sb.Alternate Facility(or Generator) <br /> v <br /> w Facilelyy s-Phone:`" Month Day Year <br /> O 18c.Sighatuha of Alternate Facility(or Generator) <br /> 1 Q <br /> Z <br /> }y e{a ardcus 9Vaste Rept Maeagement Metliotl Cedes(i.e,codes for hpzardot$waste(reatment,disposal,and recycling systems) <br /> O L <br /> 2LU <br /> 3. <br /> ; H141 <br /> 2C I resigoaled Facility Dsvner or Operator.Certif it ttioo of receipt of haiardous materia covered by the manifest except as net item 18a Mo1jh Day year <br /> I <br /> Signature <br /> I P sled Tyoed Name <br /> EPA Form 8100 22(Rev.12-17)Previous ecliti0ns ate Ob ietc. <br /> DES1G ELI- 1LITY TO EPA's e-MANIFEST SYSTEM <br /> i <br /> i <br />