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'Ise print or type"(Form designed for use on elite 12-itch <br /> HM80�ililkdtll�I�IIIII��I�IIIII��i�ll III <br /> `'v'FORM H ( -pitch)tYPewriter.) Form Approved.OMB No.2050-0039 <br /> AZARDOUS 1.Generator lD Number 2.Page 1 of 3.Emer en Response Phone 4.Manifest Tracking Number <br /> 11 ,VASTE MgNtFEST �AL000359848 1 800�2!-r6804 012039614 Numb <br /> F L E <br /> 5,Generators Name and Mailing Address <br /> Save Mart #655 Generators Site amss(it different than mailing address) <br /> 2093397170Save Mart#655 <br /> Genetors Phone: Lodi, CA 95240 <br /> SW. Lodi Ave. 530 W. Lodi Ave. <br /> ' I ra <br /> 6.Transporter Company Name Lodi, CA 95240 <br /> Specialty Waste Solutions Inc <br /> Staric cle Sp U.S.EPA ID Number <br /> MNS000110924 <br /> Y <br /> ' l <br /> 7.Transporter 2 Company Name <br /> L U.S..�E/P�A ID Number /� <br /> ( 8.Designated Facility Name and Si Addres �� 1"V q <br /> t 5 en ury U.S.EPAIDNumber <br /> 20135 Newlands Dr. East <br /> " <br /> Facility's hone:77557527Ei0 Fernley, NV 89408 <br /> 9a. 9b.U.S.DOT Description(including Pro per Shipping Name,Hazard Class,ID Number, N VD980895338 <br /> ++ HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> I' n, x 'IN1950 ' No. Type Quantity wuvol. 13.Waste Codes <br /> Waste Aerosols, [flammable (each oat 1 CF 00024 P 214 D001 ' <br /> exceeding 1 L capacity)] 2. 1, ERG#126 <br /> ru <br /> W X �1N1993, Waste Flammable liquids, n.o.s. 2 <br /> (Acetone, Alcohols), 3, PG II, ERG#128 CF 00054 P 214 D001 D035 <br /> 3. <br /> f ' <br /> \ .. 4. <br /> 14.Special Handling InsWctions and Additional Infortnafion <br /> i <br /> 1. 100498(Aerosols) 2.100499(Flammable Liquids) <br /> It` <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shippingC <br /> marked and labeled/placarded,and are in all raspects in proper condition for transport according to applicable international and national governmental regulations,If xMx rt 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 Ural the waste minimization statement identified'n 40 CFR 262.27(a)(iF I am a large quantity generator or <br /> Generatoesroffe ypjed�Nam]e�� j. ) a small quantity erator)is true. <br /> akTr,.z, r onay <br /> Year r <br /> =J16.Intemabonal Shipments 09 07 1201 <br /> Trans iter si nature onl ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> � for ex rts <br /> w 17.Transporter Acknowledgment of Receipt of Materials Dateleavin U.S.: <br /> Transporter 1 Prinim Typed Name <br /> Ignature <br /> 1 Melissa Ballard I on ay ear <br /> Trans po ter 2 P ntedrfyped N Sign re I 09 I 07 201 <br /> Month Day Year <br /> 18.Discrepancy �`' ClW 18 <br /> 18a.Discrepancy Indication ❑ <br /> Space <br /> Quantity EJ Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> i <br /> 18b.Altemate Facility(or(3enerator) Manifest Reference Number. <br /> "'r U.S.EPA ID Number <br /> Q ' <br /> rL FaI s Phone: <br /> Signature ofAltemate Facility(or Generator) <br /> -� Month Day Year <br /> (.'Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � ' �A `I 2 P 1 — t t 3 <br /> 4. <br /> 20,Designated Facility Owner or Operalor.Certification of receipt of hazardous mate als covered by the manifest except as noted in Item 18a <br /> PrintedfT d Name <br /> �° ^ Signaltire <br /> Month <br /> EFA Form 8700-22(Rev.3-05) Previous editions are obsolete. Day Year <br /> = _ SIGNATED FACILITY TO DESTINa <br /> 4`., i J <br />