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1 � 002198772PSC 3542379-001 <br /> PIPAse prJo.or typi&., Foi tApproJel.OMB Na.2050-0039 <br /> yNIFORM HAZARDOUS 1.Generator ID Number 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000397555 1 (877)577-2669 002198772 PSC <br /> 5.Generatnr s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ROSS STORE#0826 ROSS STORE#0826 <br /> 1086486 <br /> INITY VKWY 104 TRINITY PKWY <br /> STOCI&ON,CA 95219(209)474-9518 STOCKTON,CA 95219 2094749518 <br /> Generator's Phline': <br /> 6.Transporter t Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNS000110924 <br /> '.Transporter 2 Company Name. r U.S.LPA IU Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21 at Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> 9a. 9h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(f any)) 13.Waste Codes <br /> No. type QuantityWt.IVol. <br /> 1. UN2810 WASTE TOXIC,LIQUIDS,ORGANIC,N.O.S.(LEAD,SILVER)6.1 PGII <br /> � - 331 D006 D008 <br /> tOF X 1 DP 48 P ----- <br /> rx D011 D016- <br /> W <br /> W 2. UN1950 WASTE AEROSOLS 2.1 331 D001 <br /> r� X <br /> 1 DP_ 4 -P ...., <br /> 0 <br /> I <br /> f <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> (1)ROSS6.1-06-ERG(163)ROSS6.1-06-TOXIC LOOSEPACK(2)ROSSAERO-06-ERG(126)ROSSAERO.06-AEROSOLS <br /> 15. GENERATOR'SIOFFEROR'S CERARCATION:t 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 respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,1 certiily that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimizatiun statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(el I am a s2.k44uanfity generator)is true. <br /> Genelt i offe,or's Pri ted/typed Name Signature Month (lay Year <br /> r�J'� h 5 1 19 <br /> 16.International Shipments <br /> f- ❑Import t .S. ❑Export from U.S. <br /> ? Transporter signature(for exports only): Date leavi <br /> cr 17.Transporter Acknowledgment of Receipt of Materials <br /> a Transporter t Printed/T ed Name Sign re Month Day Year <br /> �sPCOU &/i SA 5 1 19 <br /> Q Transporter 2 Printedfiyped Name �� ® � alure Month Day Year <br /> 78.Discrepancy <br /> 18,t 1)iscrepanr,.y Indication Space C Quanta <br /> Y ❑Type ❑Residue L1 Partial Rejection ❑fu!I Rejection <br /> 78b.Alternate Facilely(o Manifest Reference Number.Generator) U.S.EPA ID Number <br /> U <br /> L� Facilitys Phone: <br /> W 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> t <br /> H141 2. 3. a. <br /> H141 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest ex .pt as noted in Item 18a <br /> Prer dff p_iName - Sigln tura - Month Day Year <br /> EPA FDrm 7002 Rev.12-17) Previous editions are obsolete. (}ESIGNATED FACfLITY T4 EPA's e-MANl�EST SYST"EM <br />