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- - _ Illlllllllllllllllll�llllll�llllll - <br /> 53 a 95-19 002544157PSC =. 37435,4 01 <br /> -Please print or type., ` Form Approved.OMB No.2050-0039 <br /> UNIFORM HkZARDOUS L Generator ID Number 2-Page 1 of 3-Emergency Response Phone 4 Manifest Tracking Nurnher <br /> WASTEMANIFEST CAL000397555 1 (877)577-2669 002544157 PSC <br /> 5.Gaaefatnrs Name and Mailing Address Generators See Address(if different than mailing addrassl <br /> BOSS STORE#0826 ROSS STORE#0826 <br /> 10864 TRINITY PKWY 10864 TRINITY PKWY <br /> STOCKTON,CA 95219(209)474-9518 STOCKTON,CA 95219 2094749518 <br /> Generators Phone. <br /> 6.Transporter 1 Compary Name U.S EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNSIMI-Il 924 <br /> 7.Trans oder 2 Company Name US.EPAID Number <br /> f S r Q LL� 93 Y-2 9 <br /> 8.Designated Facility Name and Sill Address U.S.EPA ID Number <br /> 21st Century Environmental Management of Nevada LLC NVD9a0895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> FaGi€ity'S Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Cantainers 11.Total 12.Un i1 13 Waslocodes <br /> HM and Parking Group(if any}) No. Type Quantity W1.Nol. <br /> 1. UN2810 WASTE TOXIC,LIOLNDS,ORGANIC,N.O.S.(LEAD,SILVER)&1 PGII <br /> � 331 DDOB DDOB <br /> Q x 1 DF 116 P <br /> C D011 D016 <br /> 2 2 <br /> W <br /> C] <br /> 3. <br /> 4. <br /> 14.)Special Handling Inslruchons and Addi ions l i nformation <br /> ROSS5.1.07•Eil531 ROSSB.7.07•TOXIC LOOSE PACK <br /> 15. GENERATOR'SFOFFEROR'S CERTIFICATION: I hereby declare that the eonlents of this consignment are fuly,and accurately described ahove by the proper shippng name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition toll transport according to applicable international and nahona4 governmental reguiations.If export shipment and I am the Prmlary <br /> Exporter,I certify that the contents ofpis consignmenl conform to the terms of the attached EPAAcknowledgment of Consent, <br /> cedily that fie waste minim talion statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)II am a small quantity generator)is true. <br /> G rat 's'Offerar s PnnledlTyped Name SignalMon h Day Year <br /> ]2. 22. 10 15 1 19 <br /> 15.international Shipments <br /> ❑Import 10 U.S- ❑Expwt from U.S. Port of enl <br /> ? Transporter signature(for exports of Date leaving U.S., <br /> 17.TransporlerAcknmk-dgmentol Receipt of W[eriaEs <br /> Transporler 1 ll"nr dll'y d Name S y Manlh Day Year <br /> v � j 10 15 19 <br /> CL <br /> Z Transporter 2 Prinledrryped Name Signature Month Day Year <br /> M :. r <br /> 18-Discrepancy, <br /> 18a.Disc reponcy Indication Space ❑ ,lily ❑Type ❑Residue ❑Padial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 1%Allemate Facility(or Generator) U.S.EPA ID Number <br /> 1 <br /> U <br /> Facility's Phone: <br /> w 18c.Signature d Altemate ll(or Generator) Month Day Year <br /> z <br /> 19 Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste Ireatment,disposal,and recyckng syslerl <br /> Q 'I. 2. 3- 4. <br /> H141 I I R <br /> V <br /> 2C.DL Facility Owner or Operator.Certification 01 receipiof hazardous materia€s covered by the roan s[exeept as noted in Item 18a <br /> PriniedItypedN e Sig slurs Month Day yeET <br /> 4r\ <br /> EPA Form 8700-22(W 12-17) Previous Pill are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br /> 1 <br />