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�lli�l�l00�[0i9429l2lPSllfllll�ll. :, � 3a3s5ss-nv Fs <br /> Please Wiltoriype.(Fonndesgned for use on elite(12-pitch]typewriter.) b Form Approved.OMB No.2{]5&0039 <br /> UNIFORM HAZARDOUS 1,GeneratarIUNumber . . 2.Paget of 3.EmefgencyResponsePhone 4..Manifest Tracking Number <br /> WASTE MANIFEST CALp00397555 1 (877)577-2669 002094292 PSC <br /> 5.Generators-Name and Mailing Address Genoralcr's Site Address g different than mailing address) <br /> ROSS STORE#0826 ROSS STORE#0826. <br /> 10864 TRINITY PKWy' 10864 TRINITY PKWY <br /> SSTOCKTON,CA 95219(209)474-95i18 STOCKTON,CA 952102094749518 <br /> b transporter 1 Cr mpany Name - .U.S,EPA 10-Number.. <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNSOM110924 <br /> 7.,1 ransporler 7 CAmpany Name r �I - U.S.EPA IP Number <br /> S Designalrsd Facility Name and Sle Address U.S.EPA Ib Number <br /> 21st Century Environmental Mlamagement.g4 Nevada LLC NVDM;395338 <br /> 2095 Newlands Dr.East, <br /> Fem ley NV 89408 (775)575-2760 <br /> F3CIIityS�'lDnc.: - - <br /> 03. 9b.U.S.b0T Description(including Proper Shipping Name,qazard Class.ID Number, 14.Conlainers ]t.Totat. 12.Upd 13. Waste Codes <br /> Hf.; and Pacldng Group.(f any)) 140. Type .Ou8plity. WI.Noi" <br /> +. UN281a WASTE TOXIC.L10UIDS,ORGANIC,N.O.S.(LEAD,SILVER).5,1.PGII- - 331 coos .Ucaa <br /> d '..x t OF 11 P <br /> Q Doll .D016Uj <br /> , <br /> rr . <br /> .2 - 2. UN1960 WASTE AEROSOLS 2.11 OF ID <br /> - - <br /> 33i 000 <br /> 3. U1,11 993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGH 331: CJW! <br /> 4.: <br /> .14,Special Handling Inslydctions and Additional Imfomlat cn <br /> (1)RQSS6-1-06•ERG(153)ROSS6.1-W-TOXIC LOOSEPACK(2)ROWAERo-O6-ERG(126)ROSSAERO-06-AEROSGLS[3]ROSSFLAMM-06 rflG(12e)RO,,SSFLA#AM:06•FLAMMABLE. •�F_ <br /> L00SEPACK -- <br /> 15.- GOIERATOWSIOFFFROR'S CERTIFICATION: hEreby.declare Thal the contents of this consignmentare fully and accuratdydascritled above 60-ow proper shipping name;and are classiiied.paGfaged <br /> marked and 4boW0jacafded,and are in all respects in proper condit ori for transport according to appicable inlemlitional and national goverorwal regulation-11'export shipment and h aro the Primary <br /> Cxporiar,i certify Ihat the eontenls ofthis consignment conform to the.terms of the.attached EFAAcknowledgrnent of Consenl. <br /> 1 cerlily thalthe waste minimisation statement ldenliried in 40 CFR 261.27)a)(if I an:a large quanl" alor),or j (f I an a small quantity generator)a frue. <br /> nio?sr er s .rin y g ure ay Far <br /> C r�'n11 1 10 19 <br /> a 16 International Shi 1s <br /> ET ❑€mport In U S ❑Ewe from U 5. Porl otenlrylex' ----- —__ --- —— - <br /> x. Trans ter s! nal a tore rlson AIrvin .S.: r <br /> 17 TranssAckrroL 9mrt of Receipt of Materials <br /> Tfanspq.ftr1NnSipal Month Day eaz <br /> EOL Darryl Johnson = 1 10 19 <br /> z Tfansporler 2 Printedt7yped Name Signature Month Uw Year <br /> 19 Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ouallwy ❑Type ❑Residue ❑Partial Reimion Q Full Reoclion <br /> Manifest Reference Number" <br /> 19ti.Allernate Facility(or Generator). U.S.EPA l0 Number <br /> FaCili!'s Phone'. - <br /> . 18c.Signature of Alfemate,Facility(or Generator) Month Day Yuar <br /> z <br /> 19 tiatardous Waste Report Managemeot Method Codes(i.e.,codes for hazardous waste treatment:disposal,and recycling systems) <br /> 1 2.. 3. 4. <br /> H141 H141 H141 <br /> 2i [3eswnaled Facilily Owner or Operator,Certdication off eceot of hazardous materials covered.by the rr4lifesl excepl as noted in Item 18a <br /> Signa <br /> FpA. crrr7 87 <br /> W." Previoth e "ons Ire obsolete. <br />