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JLIIIIIIIII IlNilllllllull 1.111111111 . <br /> 584625-19 002572259PSc 3771659-001 <br /> Please print or type Form Approved.OMB Na.2050-0039: <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page.1 of: 3.Emergency Response Phone 14.Manifest Tracking Number. <br /> WASTE MANIFEST CAL000397329 1 (877)577-2669 002572259 PSG <br /> A Generators Name and MailingAddress : 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 /> Generators Phone: . <br /> 6.Transporter 1 Company Name US,FPA1D Numbs <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7.T ansporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated,Facility Name and Site Address U.S:EPA Ip Number <br /> GENERAL:ENVIRONMENTAL MGT.LLC DBA PSC ENVIRONMENTAL SERVICES CAD980884183 <br /> 11855 WHITE ROCK ROAD, <br /> RANCHO CORDOVA CA 95742 (916)351.-0980 <br /> Facility.'s Phone: <br /> 9a 9b.U.S.:DOT:Description(including Proper Shipping Name,Hazard Class;ID Number, 10,Containers Tl.Total 12.Unit 13.Waste Codes <br /> HM and Parking Group(if any)).. No. Type Quantity Wt./Vol. <br /> -. 1. Vii- a w STS,AERAS^�sl cy-9it�I <br /> - - D001 r <br /> OccX <br /> Q <br /> W2. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII D001 <br /> t9 x 1 DF 5 P <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> : ()ROSSAGM1111111i EFFOAU15)KEF6bArK0Mr-_XERV5X1M(2)ROSSFLAMM-07-ERG(128)ROSSFLAMWO7•FLAMMABLE LOOSEPACK <br /> I� <br /> 15.-GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by lhe.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 nationa(governmentat regulations.if export shipment and 1.im the Primary <br /> Exporter,I.certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.' <br /> I redify:hat the waste minimization statement identified in 40 CFR 262.27(a)of I am a large quantity generator)or(b)fill am a small quantity generator)is true. .. <br /> Generator.'Offeror' Prinf dfryperi,Name. Signature Month Day Year <br /> Y1 12 19. <br /> � 1 ntemap hrpments _ , - <br /> El Import to U S. ❑Export from U.S. Pat of entrylexit; <br /> Transporter signature(for exports only): Date leaving U.S.' . <br /> ¢ 17:Transporter Arknowkadgment of Rer eipt of Materials <br /> W <br /> Transporles l Printod,,9yp Name Signature Month Day Year <br /> o 1i 12 19 <br /> a .. <br /> Z Transporter 2 Punted/Typed NWe .. Signature Month Day Year. <br /> a . <br /> rs <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space.' ❑ QuantityEl . ❑f' <br /> Type -❑Residue adial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facility's Phone: <br /> w 18:.Signaturs of Alternate Facility for Generator) Month Day Year <br /> Q _ , <br /> Z - ..:- ... .- .. <br /> (74- 19 Hazardous Waste Report Management Method Codes(i.e;,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 3. <br /> 141. <br /> H <br /> 26,Designated Facility Owner-or Certification of receipt 0 hazardous matetials covered by the manifest except.as tided in Item 1 <br /> PrinledfrypedName Signature Month Day Year <br /> Artmet <br /> EPAForm8700-22(Rev,12-17)Previous editions are obwlete. DESIGN ATEDIFACILITY TO EPAs e-MANIFEST SYST M... <br />