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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 Phone 4.Manifest Tracking Number WASTE MANIFEST CAL0100397329 2 (800)326-1221 !W' 5.Generators Name andMailigAddress__.-.._.- .__.. _ -_ -_._ ______ _--Generator's Site Address(rfdifferent than mailing address) ROSS ROSS DRESS FOR LESS (t 035) 5756 PACIFIC AVE STE 60 5756 PACIFIC AVE STOCKTON, CA 95207-5156 STOCKTON CA 95207-5160 Generators Phone: (209)957-6202 GEN: 208§35 6.Transporter 1 Company Name U.S.EPA ID Number HERITAGE TRANSPORT LLC - TS HAYWARD IND058484114 7.Transporter 2 Company Name L U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number HERITAGE ENVIRONMENTAL SERVICES 284 E STOREY RD AZD091705402 COOLIDGE, AZ 85128-9205 Facility's Phone: (520)723-4167 ga_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.1vol. 13.Waste Codes 1. of o _ RQ UN1950 WASTE AEROSOLS FLAMMABLE N.0.5, ,2. 1, HINT, LUBRICANTS), (D001),kRG#126 z 2. CD RID UN 1993 WASTE FLAMMABLE LIQUIDS N.0. ,S , �' i t .3,P(M, (PAINT, ACETONE), (D001 U502),LRG#128 3. NON RCRA HAZARDOUS WASTE LIQUID (WATER BASED PRODUCTS) ' 4. NON-DOT/NON-RCRA REGULATED, (ELECTRONIC WASTE) 14.Special Handling Instructions and Additional Information 1.W1 014,,i772D LDR 2.W137 01457639_LDR 3.1414 0.1456798 4.W12 01458 hr C1301456236T 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shlpping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national govemmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a)i ff I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. enerators erors PRnted/Typed Name rgna re �- on ay ear Vet ux>L A 1-0ani 3 1 0 -r 16.InternatifThal Shipments z ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Trans rtersi nature for exports onl : Date leaving U.S.: L 17.Transporter Acknowledgment of Receipt of Materials Sj Transporter 1 rintedtTyped Name t Signature Monthay Year y !!� QTransporter 2 P tedl yped Name ig r Month Day Year e w V13 L 18.Discrepancy 18a.Discrepancy Indication Space 11 Quantity ❑Typej j ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V Facility's Phone: LaLl 18c.Signature of Alternate Facility(or Generator) Month Dav Year Z 19.Hazardous Waste Report Management Method as(i.e.,codes for,hazardous waste treatment,disposal,and recycling systems) Cn ® 1. 2. 3. / 4. H141 H141 � / 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous dltlons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)