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Please nt or Form de for use on elite 12 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS WASTE MANIFEST 21 Generabr ID Nw bw 1 22.P 23.MaeUnt Traddng Number <br /> (Continuabon SMeq CAL000018659 0 t 000240941 WAS <br /> 24. KMART # X174 / MC&C CLERK <br /> 3333 BEVERLY ROAD 2180 E. MARIPOSA RD. <br /> HOFFMAN ESTATES, IL 50179 STOCKTON, CA 95205 <br /> 25.Transoorfer_ Company Name U.S.EPA V Number <br /> Number <br /> 26. Transporter_ Company Name <br /> 27a. 27b.U.S.DOT DesatOon(vxftK rq Proper Shipping Name,Hazard Clan,ID Number. 28.Containers 29 Total 30 Url 31.Waste Codes <br /> HM and Padmg Group(W any)) No. Type Ouantity WtNd, <br /> X 5. RQ UN2929,WASTE TOXIC LIQUIDS, FLAMMABLE, D001 D016 <br /> ORGANIC N.O.S. ,6. 1 (3) PGII, ( /)1,� �. <br /> (PENTACkOROPHENOL, 2, 4— -Cr G `�I 331 <br /> 5. DICHLOROPHENOXYACETIC ACID), (D037 D001), X)(X XX XXX X XXXX' XXXX XXXX <br /> ERG#1371 I _ <br /> X7(XXi xXXX XXXi( <br /> t '^ <br /> r L. ri / <br /> r <br /> " � P$�?III Waite1s NJ <br /> &-41106fie roldhoHsg. - <br /> x <br /> I <br /> I <br /> ) <br /> Tox <br /> kypo <br /> OC 33.Transwrier AckvAledwwi of Rempt of Materia s <br /> H Pwed/Typed Name Sgnature Month Day Year <br /> a <br /> Z 34.T i of Recetpf of Materials <br /> Pm*d/Typed Name 54nakure Mordh Day Year <br /> 35.Discrepancy <br /> J <br /> v <br /> s <br /> in <br /> 38.61TOOMS waste mem Meths Godes(ro. r zamous waste ffttment,dApg$44900�Ua ng systems) <br /> N14k <br /> rn <br /> W <br /> O <br /> EPA Form 8700-22A(Rev 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />