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<br /> 05791#-20 002671394PSc 3865821-001
<br /> or tSpe Form Approved.OMR No.2050-0030
<br /> UNIT ORM HAZARDOUS 1.Geirerainr II)Number 2,Paye 1 of 3.Emergency Re,posse Phoney 4.Manifest Tracking Number
<br /> WASFE MANIFEST, CAL000397329 1 (877)577-2669 002671 394 PSC
<br /> nerainrs Name Arid MailingA(Idress Generators Site Address(if different than mailing address)
<br /> ROSS STORE#0035 ROSS STORE#0035
<br /> 5756 PACIFIC AVE 5756 PACIFIC AVE
<br /> f STOCKTON,CA 95207(209)957-6202 STOCKTON,CA 95207 2099576202
<br /> i nt ratol s Phone:
<br /> yrs e r l 0)nipary Nanne U.S.EPA ID Number
<br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924
<br /> 1. ,;a?n-:,2 Company Name U S.E:PA ID Number
<br /> 8. .;t;t';r,i r :riy Name and Site r c t' .a
<br /> l oS.FPAID Number
<br /> 21 at Century Environmental Management of Nevada LLC NVD980895338
<br /> 2095 Newlands Dr.East,
<br /> Fernley NV 89408 (775)575-2760
<br /> n 1J S 11 D rn ii t n(including Proper Shipping Name,Hazard Class,ID Number. 10:Containers 11 Total 12.Unit
<br /> 11,x and 1 tcx.r l Gn(, (`iny)) 13.At tsb,Code,,
<br /> No Tyne .h,intify WtlVol.
<br /> I.. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII
<br /> - 331 D006 D008
<br /> �'- X 1 DF 92 P --
<br /> - D011 _D016 a
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<br /> � l
<br /> I
<br /> 1
<br /> I ,N �-i r t 'u!Inst t�u.^s and Ad iu!nnal Irformatittn -
<br /> (1)ROSS61 07-ERG(153)ROSS61 07-TOXIC LOOSEPACK
<br /> j
<br /> I� GENE RATOR'S/01FIF ROR'S CERTIFICATION:I hereily declare that the contents of this consignment are fully and accurately described above by(he pi oper shipping name,ani are classified,packaged;
<br /> k nark-1,; a W,,:A/Placa dt..d and ar?it all respects in proper condition for harispoO according Inapplicable international and national governmental lequiations.ii expod shipment and I ant flu?Poetry .
<br /> n^ ify tha ,en's of th,.coni n exit conform to the terms of the attached EPA AckriowliAgment of Consent
<br /> I'
<br /> r ai r ra a mtrnf,cr,t,t r c ern.,dt.0 dict in 40 CFR 262,27(a)(it i am a large(41.1ant0y generator)or(b)(ifI am a:mall < tity genc-mi[ i. true.
<br /> Signature
<br /> Month Da•,, Yr ar
<br /> 2 1 3 1 20.
<br /> Import to I).& Po
<br /> from U.S. Port of e ry/exi _ ._..-.._ __......_..
<br /> r t ,t,has t,rr if(i r xo trts only) Date leaving US
<br /> ix i .it�.r,<•P.rknr„t'.edymenf of F;eceipt of PAaterials
<br /> x ed;Typed Flaittc.; Signature Month Day Year
<br /> Andy Winkler 2 3 20
<br /> 1,,tted Typed Name - Signature Month Day Y(:ar,
<br /> f
<br /> Dircrenrinry f�t (�
<br /> { ' r r r rr i.a loo.Space CC,Quantity l_-t I ypr ❑Residtut L.1 Partial Rejection ❑Fkill deject oa
<br /> Manifest Reference Number:
<br /> 1 ,Mev,ate Fac;lrty(or Generator) US.EPA ID Number
<br /> 611:e ostomate Facility(or Geremtor)
<br /> ) Month - Day 'rear
<br /> Vi hazardn oiaStfl Report Management Method Codes(i ei,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> i I A
<br /> H141
<br /> t € :at, 1:c1 0.n r o!Open t(or Certification oi recciof of hazardous materials covered by the manifest except as nckdin Itern 18a
<br /> N rnnc rgna
<br /> Month Day Yrar
<br /> .v.121; 1revious e(r n:;are o o e e. ESIGtdAT FACI TO EPA's e-MANIFEST”SYSTEM?
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