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5� „x...19 111111111111111111111I�111111�1�1111 <br /> 002572159PSC 3771652-001 <br /> f'i se nnnt orlype. Form Approved.OMB No.2050-0039. <br /> UNIFORM HAZARDOUS t,Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Nwnber <br /> WASTE MANIFEST CAL000397555 1 (877)577-2669 0025721 59 PSC <br /> 5-Generators Nance and Mailing Address Generators Site Address(if different than mailing address) <br /> ROSS STORE#0826 ROSS STORE#0826 <br /> 10864 TRINITY PKWY 10864 TRINITY PKWY <br /> STOCKTON,CA 95214(209)474-9518 STOCKTON,CA 95219 2094749518 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> STERICYCL,E SPECIALTY WASTE SOLUTIONS INC MNS000110924 ' <br /> l I ranspodel 2 Company Name U.S.EPA ID Number <br /> SIC? <br /> 8 Designated Facility Name and:Site Address U.S.EPA ID Number <br /> 21st Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, _ <br /> Fernley NV 89408 (775):575-2760 <br /> F ad dJs Phone <br /> ?h.I. ?OT.Desmption.(including Proper Shipping Name,Hazard Class,ID Number, .10.Containers 11.dotal - 12.Unit <br /> �i �I,J P K nfi Group(if,any)) 13 Waste.Codes <br /> No, Type Quantity WtlVol. <br /> UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII - - -Cr .331 D606 :D068-- <br /> GO :X f 4F. 56 P <br /> Q, <br /> Do11 0016 <br /> Z 2. <br /> ,11 <br /> II <br /> ( a ; <br /> I - <br /> 14Special Handling Instructions and Additional Information - <br /> (1)ROSS6.1-07-ERG(153)ROSS6:1-07-TOXIC LOOSEPACK - - <br /> GENERATOR'S/OFFEROR'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 labelediplacarded,and are in all respecls in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> xnnner,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I;e ify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> ar.i lur's.O6erors Printe(/Typed Name S[ynat Month Day Year <br /> re L r;-I r) 11 15 19 <br /> M t tamational Shipments <br /> ❑Import to US. Export from U.S. Port of entry/exit. --�- -_--- -- —1-----_-- ---- <br /> Z .Transporter signature(for exports only): Date leaviry U,S.: <br /> OCw 1 i'Iraiupnder Acknowledgment of Receipt of Materials <br /> 2 -fransporim 1 PrintodiTypedName Signature Month Day Year <br /> a Andy Winkler 11' 15 19 <br /> 4 Transporter 2 Pr'nlediTyped Name' Signature' <br /> o� Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑0tlanidy ❑type 0 Residue ❑Pallial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F -181b Alternate Facility(or Generator)' - U.S.EPA ID Number <br /> LL FardrtysPhone: <br /> p 18c$.gnature of Alternate Facility(or Generator) PdoMh Day Year <br /> Q <br /> 2 <br /> 5,5 19 Hazardous Waste Reporf Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> LU <br /> I <br /> H141 2 13, 4 <br /> 20 Design ed Facility Owner or Operator:CedA,ition of receipt of hazardous materials covered by the rinanifest except as nded in7term 1&-i <br /> Prrn. 'yped Name - Slynat n Day Y*a' <br /> 77 Forrii A760-22(Rev.12-17)Previous editions are obsolete. DESIGN 4TEQ FAG#CITY TO EPA"s a NlFE T SY IENi <br />