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<br /> 643855-19 002605216PSC 3804601-001
<br /> Form Approved.OMR No.21XIO CIO"f!
<br /> UNIFORM HA7.ARDOUS ! G:nerlfor ID hiumbcr 2.Paye'1 of 3.Emergency Response Phone Manifest Tracking Number
<br /> WASTE MANIF=EST 4.CAL000397329 1 (877)577-2669 002605216 PSC
<br /> ':_-'r I:a Ad.+.rny, Generale ;Sue Add:( ,,( (i n ma ,I 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 /> ruler t Con pa, Name U.S.i=.PAID Number
<br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924
<br /> r I -.r T nrl iw,,Name .+ ( US EPA ID Nur.**
<br /> /,�� - .y/�ot
<br /> :+ r+ � a-i,ityNanlE mid`-i4�F. U.L fi - ri�etber
<br /> 21st Century Environmental Management of Nevada LLC NVD980895338
<br /> 2095 Newlands Dr.East,
<br /> Fernley NV 89408 (775)575-2760
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<br /> mm De'srr pI on(irw p,rg Name,Hazard Class ID Nrvnhe 10.containers
<br /> n'y;) N. Type t JI 6!iVel.
<br /> UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII 331 i D006 & D008
<br /> X1 DF 82 P —.-,...._._.�._,._._.._.._,_. .. ,...
<br /> ct: DOt t i D016 ¢
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<br /> UN3139 WASTE OXIDIZING LIQUID,N.O.S.(HYDROGEN PEROXIDE)5.1 PGI €
<br /> D001 s .,_...........
<br /> X 1 DF 62 P --�«----
<br /> 1 �I
<br /> ors acid Additional t fcri ,i.;on
<br /> '(1)ROSS6.1-07-ERG(153)ROSS6.1-07-TOXIC LOOSEPACK(2)ROSSOXILIQ-07-ERG(140)ROSSOXILIQ-07-OXIDIZER LOOSEPACK
<br /> GENERATOR SIOFFEROR'S CERTIFICATION I-iFre.,,d Clare that the onnlenls of this cu .'inmentare fully and accurately described above t)y the proper Ship nc; l'.;),,I e r.ic:,it e.-rackaged.
<br /> ima a .n);respN is n pr0pe, rondihon fpr transport according to applicable m.ernationa!and national governmental re.g.r
<br /> r•;, r.,
<br /> fy That t re.,;1.r.nts of fl in r onsignmen!conform to the terms of the attached EPA Acknovaledgmeni of Consent.
<br /> .u.Lljste mn rn r,1ho0 s.11emen,Identified to 40 CFR 262,27(a)(if I am a large quantity generator)or(h)(if I am a small gwanhty grneralor),true.
<br /> It ;Ot;r s Prnt(re Typed Name aWre Month t)ay y;•ar
<br /> 12 12 19
<br /> ❑bn,o t In U.S. ❑Export fro. ).S. Pod of entryexit:
<br /> c a n>(+or exoorls„nly) Date leaving U.S:
<br /> tL 1-x:.;�r!rtr...:r,rsJledgmen(of Re��eipt,t:4aferas
<br /> tt
<br /> t' +r'Typ .flame Signr -In ;lay yn Ir
<br /> a. 5AVQ061 12 12 19
<br /> i,r t F cY(Tynec!Name —, ,� g. tore t1 Dav Ye+r
<br /> cIle-110,01l'
<br /> as r 11 t'a!!nn .rte, ( ❑T1y!. ❑ ❑Par'al Reiectien ❑Full Reject—
<br /> Residue
<br /> Manifest Reference Number:
<br /> i;o r &tri i ac av(or General0r) U S.I-FIA ID Number
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<br /> n t,re s•nate F a(ogy(01 Gcr,e1`0101) Day W:ar
<br /> itz
<br /> 2 7 T
<br /> ra )9 ! lea:I Hepo t Waiagemr--e t M,01oc.Godes hie.,,codes for hazardous waste treatment,disposal,and recycling syst(Ims) -
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<br /> 1 2 3.
<br /> H141 H070
<br /> Zi I'.,i,.,.-alt:.;naudity Or.,t.r rr Opt:vit i Cedificabon of ece,pl of hazardous materials covered by the r1 r "r s'exc,rn!as acted in Item'I&I
<br /> u t'Typr:d t a g In ere ' I)ay �C?
<br /> f A F?l� 8 it10-22(Rev.12-17) Pievious editions are.obsolete. DESIGNATED FACILITY TO EPA`'s e-MA IFIEST SYST��t��
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