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481033-18 002047472PSC 3403945- OD1 <br /> Please prinlor type, (Form designed for use on elite (*pitch) typewriter.) Form Approved. OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 . Generator 10 Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST CAL000390053 1 (877) 577-2669 002047472 PSC <br /> 5, Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br /> ORCHARD SUPPLY # 1570 ORCHARD SUPPLY # 1570 <br /> 2650 N MAC ARTHUR DR, 2650 N MAC ARTHUR DR , <br /> TRACY, CA 95376 (209) 662-0192 TRACY, CA 95376 2096620192 <br /> Generators Phone: <br /> 6. Transporter 1 Company Name U.S. EPA 10 Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> 7, Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated Facility Name and Site Address US, EPA ID Number <br /> 21st Century E= nvironmental Management of Nevada LLC NVO980895338 <br /> 2095 Newlands Dr. East, <br /> Fernley NV 89408 (775) 575.2760 <br /> Facility's Phone: <br /> 98. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WI.Nol. <br /> i . UN1993 WASTE FLAMMABLE LIQUIDS, N.O.S. (METHYL ETHYL KETONE, ACETONE) 3 PGII 1 <br /> 09 Do01 D035 f <br /> O X 3 CW 480 P - r <br /> W <br /> Z 2. UN1950 WASTE AEROSOLS 2.2 (8) (EACH NOT� EXCEEDING 1 LITER CAM.CITY) gn%kD001 `D005 D007 <br /> X 1 OF 127 F 91- � t H � <br /> m <br /> 0035R E <br /> I <br /> a. <br /> 4. <br /> ENVIRON AENTAL, EA it H <br /> 0�jl, EPAP�, t ' /l F-]sJ r <br /> 14. Special Handling instructions and Additional Information <br /> (1 ) OSH3.07 - ERG(128) OSH3.07 - FLAMMABLE LIQUIDS - LOOSEPACK (2) OSH2.1.07 - ERG(128) OSH2.1-07 - WASTE AEROSOLS <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, packaged4 <br /> marked and laberedtplacarded, and are in all respects in proper condition for transport according to applicable international and national gavernmeniai regulations. If export shipment and I am the Primary <br /> Exporter, I cedily that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent. <br /> I cedily that the waste minimization statement identified N 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (if I am a small quantity generator) Is Imes <br /> Generalot4fterors Prntedi yped Name Month Day Yea7 <br /> �)` . �L`f1k t 12 5 18 <br /> ..r 16. International Shipments <br /> F" 1:1 Import to U.S. ❑ Export from U.S. Pat of enlrylexil: <br /> trans orler signature fa exports only): <br /> Date leaving U.S.: <br /> IX 17. TranspoderAcknowiedgmenlofReceiptofmaterials <br /> t2 Transporter 1 Printed/Typed Name ignatureon ear <br /> ay <br /> a Chris Gilliam - 12 I 5 18 <br /> Transporter 2 Printed/Typed Name bignalure Month Day Year <br /> r <br /> 10. Discrepancy <br /> 18a. Discrepancy Indication Space i ❑ Full Rejection <br /> Quantity El Type ❑ ReskJue ❑ Partial Rejection <br /> Manifest Reference Number: <br /> J18b. Altemate Facility (a S.Generator) U. EPA ID Number <br /> 044000Q <br /> a Facilito Phone: <br /> w 180. Signature of Allernata Facility (or Generator) nth Day Year <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Whod Cedes fia.. codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 H141 2 H141 3. 4. <br /> 20. Designated Facility Owner or Operator: Certificatlon of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> Print !Typed Name Sgnalure Month Day Year <br /> EPA Form 8700-22 (Rev. 3.05) Previous edllion9 are obsolete. <br /> GENEFtATOR'S <br />