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z11111111111111111111111111 <br /> 1111111111 42 2-0 <br /> 37 65 <br /> 35 72-19 - 002543@46PSC c <br /> Please pnol or type. Form Approved.OMB Na.2050 003J <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phan 4.Manifest Tracking NumberC�1 CAC �+ <br /> WASTE MANIFEST CAL000397329. 1 (877)577-2669 0025436x46 PSC <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) . <br /> ROSS STORE#0035 ROSS STORE#0035 <br /> 5756 PACIFIC AVE 5756 PACIFIC AVE <br /> CC STOCKTON,CA 95207(209)957-6202 STOCKTON,CA 95207 2099576202 <br /> Gegei.alors Phone: <br /> U.S.EPA ID Number <br /> 6 Transporter i Company Name <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> W Tfansperier 2 Company Name U.S.EPA ID Number <br /> 2 Designaled Facility Name and Site Address U.S.EPA ID Number <br /> GENERAL ENVIRONMENTAL MGT LLC DBA PSC ENVIRONMENTAL SERVICES CAD980884183 <br /> 11855 WHITE ROCK ROAD, <br /> RANCHO CORDOVA CA 95742 (916)351-0980 <br /> Fanhtys Phone: <br /> 91b.U S.DOT Descnplion(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> tlh4 acid Parkin( Group(if any)) No. Type Quantity Wt./Vol. <br /> 71—WIN 958 WAS:,FE AGROG966 2-2(111 9004 <br /> a X <br /> Y <br /> W <br /> 2. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII F331D001 <br /> LLI <br /> X 1 DF 9 P <br /> 3.. <br /> pecial Handling Instructions and Additional information <br /> 11 S <br /> (2)ROSSFLAMM-07-ERG(128)ROSSFLAMM-07-FLAMMABLE LOOSEPACK <br /> q <br /> 15. GENERATOR'SIOFFEROR'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,packaged, <br /> marked and labeledlptacarded,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 Primary <br /> Expo iter,I Certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Conseht <br /> I certify that the waste minim zat on <br /> statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) b)(if I am a small quantity generator)is true. <br /> (,en.r for sroeo or s Printed:'Typed Name Signature Month Day Ye,:r <br /> +M knA �i�t 10 18 19 <br /> .ntema5onaf Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port ofentry/exit: . — — <br /> Tmnsporlei signature(for exports only): AatL <br /> iz <br /> 17 13nsportei Acknowledgment of Receipt of Materials <br /> firan5porter 1 Printed;typed Name Signature Month Day Year <br /> a Darryl Johnsoni4-� 10 18 19 <br /> Z Traaspixter 2 Printed/Typed Name Signature Month Day Year <br /> rZ <br /> r <br /> 18 Discrepancy <br /> [13a Discrepancy indication Space El Quantity p Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> u4.. Facility's Phoria: Month Day Year <br /> 1&.Signature of Alternate Facility lot Generator) <br /> Q <br /> 19 Hazardous Warne Report Management Method Codes(i4.,codes for hazardous waste treatment,disposal;and recycling systems) <br /> 3. <br /> o f. . <br /> 2 q <br /> H141 <br /> 20.Designated Facility Owneror Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a pay Year <br /> PrinledlTyped Name Signature. <br /> EPA Form 8700-22(Rev.1217) Previous edltiorls are obsolete: DESIGN Ep FACILRY TO EPA's e-IVtANTES1 SYSTEN{ <br />