Laserfiche WebLink
f <br /> ll pp <br /> IrIIIIII�11II11 IIIIIIIIIIII I I VIII III <br /> 644024-19_, 002605377PSC <br /> n::.:print or tt pf'. P3804691-00 <br /> 1.Generator ID Numbe Form Approved.OMB Ne:2050-00' <br /> !W=ASTE <br /> AZARDOUS 2 Paye 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> ANIFEST CAL000397329 1 (877]577-2x69 0026.05377 PS <br /> b.Ge er Mars Name mil Mai ny AtldreSS Gener)trirsSi10 Address(it dill <br /> than mailingat!dress} <br /> ROSS STORE#0035 ROSS STORE#0035 <br /> 5756 PACIFIC AVE 5756 PACIFIC AVE <br /> STOCKTON,CA 95207(209)957-6202 <br /> Genominr,Phone: STOCKTON,CA 95207 2099576202 <br /> i frm;spodhr 1 Company Name <br /> U.S.EPAID Ni.imbe: <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC IMNS000110924 <br /> T an,porler 2 Company Name <br /> U.S.EPA ID Number <br /> E <br /> Eac lily Name andSite Address <br /> ENVIRONMENTAL MGT LLC DBA PSC ENVIRONMENTAL SERVICES U.S.EPAID Number <br /> ITE ROCK ROAD, CAD980884183 <br /> CORDO"CA95742 .(916)351-0980r>:UG 1 Desi ription(i r!+.�. Prover Shtopina Narne,Haa3rd Class,ID Number, .Containers. <br /> tr. a+rt'P rck:eg Group(ifany 10Ct11.Total 12,Unit. <br /> No. Type Quantity iNt;VoL 13 Waste Codes <br /> O x - ti <br /> I - w 2. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII <br /> C7 X 331. D001 <br /> 1 DF 44 P <br /> f <br /> 4 I <br /> (3 4 <br /> t"- <br /> n, a <br /> t ';poria!!+axlurr,!n rut:.tionsarid Addition a!!nformatron p <br /> ROSSFLAMLI-07-ERG(128)ROSSFLAMM-07-FLAMMABLE LOOSEPACK <br /> leo� 11A �C <br /> Ea. GENERATOR'StOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consig ent are fully and accurately described above by the proper shipping name,and are classified,packs ed, <br /> t uk:d nrd taheied plan arded.and are in all respects in proper condition for transport according to applicable international and national governmental iegulalipns.It export shipment and I am thu Primary <br /> Fxporter.I versify that'the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> re `y that the waste muumizafum statement identific-ohl 40 CFR 282.27(a)lift am a large quantity generator)or(b)(Ill am a small quantdy ge+emtor)is true. <br /> nr rilor.;;Offetor's PrinlcBlTyped Namr� <br /> * " A Qi g store <br /> ���t Month Day Year <br /> j f In rr•ational Shipments. J <br /> 121 12 19 <br /> ❑lmpori le U.S. ❑Export from S <br /> . . ort of entrpexit <br /> � .rnr onler srgnature{fnr izaports anlyJ: P .-....... <br /> _.._... --- ..-_... <br /> _._-..__ <br /> w <br /> I a,;,pnrterA±:knowiedyment <br /> of.Receipt of Material s Date leaving U.S.: <br /> drTy Name <br /> O Signature <br /> F � � V Month Day Year <br /> a f r t•;tipp ter I_Prm!21!iyped NNme 12 1 12 19 <br /> cc Sign, <br /> Month Day Ye<u <br /> 8: n,pan;-y <br /> !Rit r)o'�epan('y Indication Space <br /> ❑ Quantity ❑Type ff��t <br /> ❑Residue <br /> LJ Parti, Rejection W Full Rejection <br /> tr— 185 Alternate Facility(or Generat)r] Manifest Reference Number: <br /> tj U.S.EPA ID Number <br /> I<- F'ariPy's Phone: <br /> Lu 0 18r. S91'alure 4AIwill—e Facaity(or Generator) <br /> Month .D+Iy fear <br /> s9 Rt+zaui+:us frasba Repo+Management Me!Iwd Cone„(i.e.,codes for hazardous <br /> LU , waste treatment,disposal and recycling systems) <br /> O '. 2. <br /> 14141 3. 4. <br /> 2Q I)r it'natcd Facility Ov;nor or Operator,Certification of receipt of hazardous mater ads covered by the manifest excepfas ntfed in Item 18a <br /> P�intR.J'iyped P.tame <br /> ^-- � Signature <br /> . Day <br /> .Month <br /> EPA Foirri 8 it)0-22 tRtw 12-17 Year <br /> etlitian�are obsolete. <br /> ESIGNAT AClLITY TQ CPA's -MkNiFEST SYSTEVI <br />