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• Illlllllllllilllllilllllllllllnllll� , / >I_ � � 001412-AAL002094299PSC rSV 3438599-001 Please print or type:(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No:2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response 777nifest Tracking Number WASTE MANIFEST CAL000397329 `-. 1 (877)577-2669 002094Z99 PSG 5.Generator's Name and Mailing Address. Generator's Site Address(if different than mailing address) ROSS STORE#0035 ROSS STORE#0035 5756 PACIFIC AVE 5756 PACIFIC AVE STOCKTON,CA 95207(209)957-6202. STOCKTON,CA 95207 2099576202 Generator's Phone: 6.Transporter I Company Name U.S.EPA ID Number STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number Q . 8.Designated Facility Name and Site Address U.S.EPA ID Number 21st Century Environmental Management of Nevada LLC NVD980895338 2095 Newlands Dr.East, Fernley NV 89408 (775)575-2760 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,.ID Number, 10.Containers 11.Total 12.Unit13. Waste Codes HM and Packing Group(if any)) No. Type QuanMy Wt.Nol. .. 1.. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.,(ACETONE)3 PGII 0 .. .. -331 D001 Q x .` ..... - . ' - 1 - '.DF. 31 P Z2. UN1950 WASTE AEROSOLS 2.1 _ - 331 D001 X 7 bF9 P. 3: UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)Cl PGII. 331D006 -D008 Doll D016 4..UN3264 WASTE CORROSIVE LIQUID,ACIDIC,INORGANIC,N.O.S.(HYDROCHLORIC ACID, . PHOSPHORIC ACID)8 PGO - ..'. 791 D002 X - 1 OF 1 P. 14.Special Handling Instructions andAddittonal Information (1.j ROS$FLAMM 06-ERG(128)FtOSSFLAMM-06-FLAMMABLE LOOSEPACK(2)ROSSAERO-06-ERG(126)ROSSAERO-06-AEROSOLS(3)ROSS6.1-06-ERG(153)ROSS6.1-06=TOXIC LOOSEPACK(4)ROSSACID-06=ERG(ts4)ROSSACID-06-,ACIDIC CORROSIVE LOOSEPACK - 15..GENERATOR'S/OFFEROR'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,pa;c d marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Pr maty Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimU tion statement identified in 40:CFR 262.27(a)('d,I am a large quantity generator)or(b)(if I am a small quantity generator)is true. nerator'sl ros nn )pM Name. Sinure. Month Day Year t 11 19 1 16.International Shipments F ❑Import to U.S: Export .S. Port of entry/exit Z Transporter signature for exports only): Date leaving U.S.: W •17:TransporterAcknowledgmentofReceiptofMaterials Transporter 1 Printed/ryped Name Signature Month Day Year eL .Andy Winkler ) 1 111 ( 19 QTransporter 2 Printedryped Name Signature Month Day Year 11,6 18.Discrepancy l8a.Discrepancy Indication Space - Quantity ❑Type Residue E Partial Rejection DO Ruction Manifest Reference Number: 18b:Altemate.Facility(or Generator) U:S.EPA ID Number J u. Facili 's Phone: Q18c.Signature of Alternate Facility(or Generator) Month Day Year Z 19,Hazardous Waste Report Management Method.Codes(r.e.,codes for hazardous waste:treatment,disposal,and recycling systems) Lu 2: 3. 4 H14t H141 H141 " 20.Des nated Facility Owner or p 9 ty Otte rotor Cerbficat on of receipt of hazardous materials covered by the manifest except as noted in Item 108 m i ff dl a Y EPA rm 700-22.(Rev.3-05) Previous�edifions are obsolete.