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355704-18 <br /> Please print or type, Form Clesloned for use an elite it2-pitch)typewriter,) 3321885 <br /> UNIFORM H 1.G tarsier!D Number Form Approved,OMB No.2050-0039 <br /> A2ARDOUS 2 Page t of 3.Emerge, y Response Phone 4.Aan'I i Tracking um <br /> WASTE MANIFEST n�) �t-r'r:. - 1.1 <br /> 000223479 DAT <br /> 5.Generatafs Name arid N "7 ailing Address Generxtar's Sita Address{if different than marling address; <br /> ROSS STORE �ae26 ROSS STORE #09211188>r4 TRINITY PKYY <br /> re51.7816d TRINITY r <br /> FtlYTraa9eaymt <br /> S.EPA ID Number <br /> STERICYCL-E Silrai, LTY wnsTE: SOLUTIONS INC <br /> 7.Tiansporfeer�rss2 Company Nama <br /> /l(i L✓�( .r, U.S,EPA JD Number <br /> 8.Designated Facility Name and Site Address <br /> YUtiA YES, LLC <br /> u.S.EPA ID Number <br /> 2738 E. ATh Street <br /> Facilli 4 ttone: YUtNI AZ 8536 (426) 642-8918 <br /> ga. 9b.U.S.DOT Description(;r6Aing proper Shipping Name,Hazard Class,ID Numter, r <br /> W. <br /> HM aridPackingGraup(irany}? tJ Containers 11 Tek! 12.unit <br /> M1`a. Type Quantity V`rt.tb'oi, 13.Waste Codes <br /> a: <br /> t. N09E BCRA rIAtARDOUS V()STE LIOUIB WIER 8Aat8 PRODUCTS) <br /> o <br /> 2, NOit-t2tRA N)}ZARDOUS WASTE, SOLID (VARIOUS CRNSUNER PRO8UCT5) <br /> 4W �2 r P _ <br /> 3 <br /> 4. <br /> 14.Special Handling instructions and Add Conal Information I <br /> {)I ROSSFNlNRE6-85 - NON RCRA/DOT RE6ULAT (i) ROa'iti11IE1 sOI-85 NON RuR$ HT REW,4T <br /> Lae <br /> 15. GENEd and la a"plaNOR'S C and <br /> are C all res i hereby par Di that the contents of D's consrgnntant are fully and aceuralely described above by the proper Wppin9 nanta,are are classified,packaged, <br /> marked and labsktdipiacxrded,and era in all respects m proper conditian tar transport auxtrifing to applicable <br /> Exporter,I certify that the contents of this consignment conform to the terms of the abacre a EPAAct gment C national governmental regulations.It expo t shipment and I am it*Primary <br /> !certify that dte waste m r miza t sm;rmerrt identified in 40 CFR 2.27(aJ <br /> ,if i am a large quantity generator]ar(b){if i am a slits i quantity Generatoeswer 9u y generator}is true. <br /> -• ', Sr- alum Month Day Year <br /> h. <br /> Fj <br /> 16.international StdpmenG; {!� <br /> i_J trnport to U.S. t ExpaR t J$ rt Of entrylexi;:--p <br /> Transporter signature(for exports ooty): ---- --._.--- <br /> 17.Trans trate feavinc 01 r <br /> porter Aeknaxledgment ai Rarxpt of Materials <br /> Transporter 1 Prinhd/Typad Name <br /> p Sgrature Ma^:tn Day Year <br /> a. �f^� �, CZ v r� _��j <br /> 7Tramr2 Print ped Nama "' / 7 i/ <br /> I-- G l � +�+�'V• f� iI� -___.....� `' Manih Day Year <br /> i8.Bisuepancy <br /> L 4- r !J <br /> iBa.Discrepancy Indication Space �— ff-- <br /> LJ Quantity ;ry£e Lam}Restoue ❑Pa fiat Re aC.it n L-1 <br /> Fun Resection <br /> 18D.Alternate facNrty far Generator) <br /> tdanitaat Reference Number <br /> —� U.S.EPA.D Number <br /> u <br /> LL Facility's phene: <br /> LL, <br /> 18c.Signature ofA tamate Facity[cr Generator) <br /> z Month Day Year <br /> 19 azardous Walk Report Management Meths!Codas 6.a,txtdes for hazardous waste treatment,disposal,and reeyoinq systems} <br /> oUJ 2 { 7 <br /> I'1 4 <br /> 20,Designated Facility Owner or Operator;C016fication of receipt of hazardous matoriats tAveted by N,a mandest t a,roes,n Item 18a <br /> PrinladlTypstp <br /> Si re <br /> _ Month ay Year <br /> EPA Form 87D0-22 Rev.3 ) revious editions are obsol�e. <br /> u 'IGN�4T�u��cI Tc uEsrrnr�rle�cv s�r�irE(r�e��aulr��I�) <br />