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Pleaseprint or type. + �I Form Approved. OMB No. 2050-0039 <br />1, Generator ID Number 2. Page 1 <br />UNIFORM HAZARDOUS � of 3. Emergency Response Phone 4: Manifest Tracking Number <br />WASTE MANIFEST rent01312 8 <br />043�G 14'4 F L E <br />5. Generator'sName and Mailin e than mailing <br />address) <br />Fasi,y Dollar # 31867 Family Dollar -_#31.8&7 <br />(209) 924-4046 2350 S. Airport Way ._'.350 S. Airport Way <br />Generator's Phone: <br />GA 95206 <br />6. Transporter 1 Company Name 5 <br />E I Number <br />,• <br />WaSt <br />on <br />_. . <br />7. Tr,porter ompany a e � <br />8. Designated Facility Name and site Address Rh o Chem, LLC VS. EPA Ib Number <br />425 Isis Avenue <br />Inglewood, CA 90301 <br />Facility's Phona-�. ter,. <br />_ , <br />go. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10 Containers 1I. -Total 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) <br />No, Type Quanty Wt,/Vol.. <br />o N1760, Waste Corr. v l iquids, Tr o.. S 1 F 40M P l.4.l. 02 <br />(Sodium H droxide, Potassium H drox14e) <br />e._8e <br />LU Xr, - 11154_ <br />3. <br />14. Special Handluuj Instructions aril Additional Inform- ipn " <br />l.1 36490asi Ligraids, Corrosive '(LodsePatk)): k' <br />..... ._ ... _ _. - . .e ..- .. <br />. x. <br />15, GENERATAR'SIOFfEROR'S CERTIFICATI©Nr I hereby declare that the tzrnt�rtls of this consr�nment are felly and e�uretgJy desald--rove by the prgper shipp)frg �r[Ie .ettd a dassifieQ packaged, <br />marked and labeled/placarded, and are in all respects in proper condibori for transport according to apPllcakle intematignalanrf rrirrl 9ove(nrdal regula6pns )f Rrt sttlRl?!btd and I,am,ilre Primary:, <br />Errporter, I certify drat the contents of this consignment conform to trig terms of the attached EPAAsrlCrtotvledgment of Consent <br />l"001* ertify that the waste miemization statement identified in 49 CFR 262.2i(a) (j i am a large quanttl�grMratgr of (b) (if l am. ;rrna11 quantJty 9erteratgr) btre <br />11 1, 11171W rots Printeti/TYped Name <br />n rter signature <br />hrfxoents I7 <br />Import to U.S, i --t t _ - of entry/®x!b <br />r <br />spo jfor exports ordy):0 ,)Raving VIS4 <br />177ranspoderAclr;n *49ment of Receipt of btateda� - <br />TiansporferMWOMPO Name - <br />n rg" <br />� <br />er _ tetll�yped Nellie <br />tt \ t atun3Do <br />py <br />r <br />19&urxglrarx.Y indication Space II ---II <br />0 Quantity 1—J Dftesidue <br />TYP © Partial P4ecbon Full Ra3jecl on <br />Manifest Reference Number. <br />i6JIt®mate Faaiity (or Generator) : _........ <br />'- U,S. EPA ID Number -_.. <br />.. s Phone: <br />fllterriate Facility jot Generator) - AfidtiUtYear <br />Y <br />fe'i�ep@rt Mghagement 141oihod CoQ (r e., catfes for hazardous waste treatment, disposal, and recysdin9 syeins) _._ _ ._ <br />azardous materials covered by the manw except <br />asn IR�1 <br />v r nature th Y r <br />vio <br />.. DESIGNATED nr.ToEPRV6,MANIFEST-S f£TEM <br />