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Please rent or e. Form designed for use on elite 12- itch typewriter.) 111111111111111 P YP (+ 9 ( -pitch) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number WASTE MANIFEST 012039703 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Marshalls #M0122 Marshalls#MO122 2099527870 2203 Grand Canal 2203 Grand Canal Generator's Phone: Stockton CA 95207 Stockton CA 95207 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc IMNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone:7755752760 INVD980895338 9a. 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)) 13.Waste Codes No. Type Quantity Wt.ftl. X 1JN1993, Waste Flammable liquids, n. o. s. 2 CF 00058 P 331 -D@10111610135 0 (ALCOHOL, ACETONE), 3, PG II, ERG#128 W Z 2. LU C9 3. I 3_ 4. 14.Special Handling Instructions and Additional Information 1. 102337(F 1 a m m a b 1 e Liquids) 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, 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 Primary 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 minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/ o Pr' ted Typed Name SignatureUnMonth ay Year 10 02 "01 rj 16.International Shipments- 1.- ipmen s Z 1:1Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printed/Typed Name Signature onth Day Year oa Melissa Ballard i 1 101 L42 1201 zQ Transporter 2 Printed/Typed Name p Signature Month Day Year aJ rci- 60t,)d c7 M 18.Discrepancy 18a.Discrepancy Indication Space ❑ QuantityType ❑ El Residue ❑Partial Rejection E-]Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number Zi U a i . Facility's Phone: LO 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z (7 fn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJI 11 u � 1 �t- 1 2 3 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 118a Printed/TypedName � � Signature '�/ r Month Day Year r 101 1 �f I EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STA`.. jF REQUIRED) 8700-22_12v3 CAL40000131 540024565 041192042 M PD100218 SD100218