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nIIII IIIII IIIII IIIN NIII SII IIIII INl 11111 llllli 111111 1111 111 1111 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> C.AL000401815 1 187751'172 ,69 012 4 9 F L E <br /> 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Marshalls #M0122 Marshall=_#01012: <br /> 2099527870 2203 Grand Canal 2203 Grand Canal <br /> Generator's Phone: Stockton, CA 95207 Stockton, CA 9520;_ <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNS000110924 <br /> 7.Transporter 2Company Name // / U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 21 St Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone:7755752 760 INVD980895338 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> X 1N1950, Waste Aerosols 2. 1, ERG#126 CF 00004 P 331 001 <br /> of <br /> w <br /> L X N1993, Waste Flammable liquids, n. o. s. 1 -F 0008' G 331 001 1035 <br /> t ALCOHOL, ACETONE), 3, fav 11, ERG#128 -- -�_ <br /> 3. t <br /> t <br /> 4. <br /> m� <br /> 4 <br /> 14.Special Handling Instructions and Additional Information 1. 1@2333(Aerosols, Flammable) 2. 102 337(Flammable Liquids) <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 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)lift am a small quantity generator)is true. <br /> Generatoor'�s/Offeror's Printed/Typed Name Signaturli behalf TJX Month Day Year <br /> 'VCM/ SNI ✓1 ZOO 03 128 4019 <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> Cr 17.Transporter Acknowledgment of Receipt of Materials <br /> I- Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> � II <br /> a Kristonher Almanza 1� `� 03 28 4019 <br /> Z Transporter 2 Printed) Iled Name Signature Month Day Year <br /> cz- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C1 <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed NameSignature - oath ay Year <br /> Ig <br /> EPA Form 8700-2212v3 <br /> .12-17) Previous editions are obsolete. SIGNATED FACILITY PA's e-MANIFEST SYSTEM <br /> 0-22 <br /> 870 _ CAL40000131 S40024565 041360254 M PD032819 SD032819 <br />