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IIINlllllll�lllllallnillllllllll) . �. , <br /> 11x$9 8-- 001844549PSC mo�ii{{ 3149741-001 <br /> Ple2se iirint or <br /> type.4Form desgned for use on elite(12-pitch)typewriter.) 353 7 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergently Response Phone 4.Manifest Tracking Number <br /> WASTEMANIFEST CAL000397555 1 (877)577-2669 001844549 PSC <br /> 5.Generators Name and Mailing Address Generalors Site Address(if different than mailing address) <br /> ROSS STORE#0826 ROSS STORE#0826 <br /> 10864 TRINITY PKWY 10864 TRINITY PKWY <br /> STOCKTON,CA 95219(209)474-9518 R STOCKTON,CA 9.5219 2094749518 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC MNSM110924 <br /> 7.Transporter 2 Co m any Name , U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address <br /> U.S.EPA Number <br /> 21st Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dlr.East, <br /> Fernley NV 89408 (775)575-2760 <br /> Facility's Phone: <br /> 9a. 9b.U.S.D0T Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group('d any)) 13. Waste Codes <br /> No Type Quantity Wt.Nol. <br /> 1. UN1950 WASTE AEROSOLS,FLAMMABLE(EACH NOT EXCEEDING 1 L CAPACITY)2.1 <br /> Q-' - 331 i D001 f <br /> i <br /> i <br /> W2. UN1993 WASTE FLAMMABLE LIQUIDS,N.O.S.(ACETONE)3 PGII - 331 t D001 <br /> C9 X. .. - - 1 DF 17 P t........._.._...... <br /> 3.UN2810 WASTE TOXIC,LIOUIDS,ORGANIC,N.O.S.(LEAD,SILVER)&I PGII 331 DOOG D008 <br /> Will Dole <br /> 4 <br /> .14.Special Handling Instructions and Additional Information <br /> (1)ROSSAERO-05-ERG(126)AEROSOLS(2)ROSSFLAMM-05-ERG(128)FLAMMABLE LOOSEPACK(3)ROSS6.1.05-ERG(153)TOXIC LOOSEPACK - - <br /> 15. GENERATOR'SIOFFEROWS 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 labeled/placarded,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.Pnmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(B I am a large quantity generator)or(b)(d I am a small enerator)is true. <br /> ner eros nmc <br /> re <br /> Month ay ear <br /> rCl �� 5 4 1 18 <br /> Z.i 16.International Shipments. p Export from U.S: rt o lex <br /> 1:1 Import to S ❑ <br /> Trans rter signature for exports only): Date leaving U.S. <br /> ,d 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Month Day ear <br /> a Andy Winkler I 15 4 118 <br /> Q Tra r2PrintedR gnature Month Day Year <br /> H 017 <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> I8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL Facij' 's Phone: <br /> UJ 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1• - 2. - - 3. 4. <br /> H141 H141 H141 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day• Year <br /> EPA Form 8Z 22(Rev.3 05) Previous editions are obsolete. <br /> t � . _ <br />