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- � ,; . IIIIIIII�LI��IIllilliilllli!11111 Q <br /> 451 002031164PSc ,y��y`/ 309-001 <br /> Please print a pe ,Font desgned for use on elite(12-pitch)typewriter.) V ✓ Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS Generator ID Number 2.Page 1 of 3.Emergency Response Phone Manifest Tracidng Number <br /> WASTE MANIFEST CAL000397555 1 (877)577-2669 002031164.PSC <br /> 5;Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> ROSS STORE#0826 ROSS STORE#0826 . <br /> 10&)4 TRINITY PKWY 10864 TRINITY PKWY. <br /> STOCKTON,CA 95219(209)474-95.18 : STOCKTON,CA 95219 2o94749518 <br /> Generators Phone:- <br /> ansporter mpany ane U:$.EPAIDNumber <br /> STE.RICYCLE SPECIALTY WASTE SOLUTIONSINC MNSOIXII10924 <br /> 7.Transporter 2 Company Nane - U.S:EPA'nI�D/N_um/1b�.er <br /> AIrV'n1 og Ls <br /> T.Designated Fadlity Name and SdeAddress U.S.EP w <br /> 21 st.Century Environmental Management of Nevada LLC NVD980895338 <br /> 2095 Newlands Dr.East, <br /> Fernley NV 89408 .(775)575-2780 - <br /> FacilWs Phone: <br /> ga 9b.U.S.OOT Description(clouding Proper Shipping,Nam.Hazard Class,ID Number; 10:Containers 11:Total 12.Unit 13. Waste Codes <br /> HM aid Packing Group(d any)) No. Type Quantity WtNd. <br /> 1. UN1850 WASTE AEROSOLS 2.1 <br /> - ._ 331 .0001� <br /> .d'. - - <br /> 0 1 .: OFUjw <br /> - :6 <br /> Z 2. UN3266 WASTE CORROSIVE LIQUID,BASIC,INORGAMC,N.O.S.(SODIUM HYDROXIDE 1n Dow <br /> LU <br /> -POTASSIUM HYDROXIDE)8 PGI <br /> X _ 1 OF . .25 P.. <br /> .- ..3.-UN2810 WASTE,TOXIC,LIQUIDS,ORGANIC.N.O.S.(LEAD,SILVER)61.PGR _ _ .331 'DOOM - DOOaX OF 76 <br /> .. <br /> . .0011 .-D016.' <br /> :4. . <br /> 14.`,peciahHandlingInsh etionsand AddfionallnfarMation <br /> (1)ROSSAERO.86-ERG( <br /> ROSSAERO-M-AEROSOLS(2)ROSSSME-06-ERG(164)ROSS13ASE-06-ALKAUNFIBMIC CORROSIVE LOOSEPACK(3)ROSS6.1-06-FJiG(153)ROSS6.1- - <br /> 06-CCOXIC LOOSEPACK <br /> 15. .OENERATOR'S10FFEROR'S 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 alt respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,i certify that the contents of this consignment conform to the terns of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(di an atarge quem*g craw)or(b)(d I an a small quantity generator)is true. <br /> C*Imqo ror's nn me re' ay Year <br /> 11 14 18 <br /> 18:Intrmational Shipments <br /> ❑Import to U.S. ❑F_xport from U S :• Port of enhyleidt — <br /> z f <br /> s xxk r s' ature fore its on -. leav' U.S <br /> Odansporter Acknowledgment of Receipt of Materials <br /> porter Prin yped Name rg re Yarryl Johnson 14 18 <br /> porter,2PrintedlfypedName n re Year <br /> 18.DLcrepancy <br /> 18a.Discrepancy Indication Space ❑Ouantity ❑Type EIResidue ❑Partial Rejection ❑Fut Rejection <br /> Manifest Reference Number: <br /> 18b.Alemate Facility(or Generator) U:S:EPA ID Number <br /> ray <br /> Fac 's Phone <br /> W 18c.S.gnatureofAlternateFacldy(orGerrerator} Month Day` Year <br /> Q <br /> N '19.Hazardous Wast Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal;and recycling systems) <br /> LL <br /> 1 4. <br /> o t H141 12. �1'I4T E'7' 3 H141 <br /> 20.Designated Facility Owner or Operator:Certification of recehazardous materials covered by the manifest except as noted in Item 18a <br /> PrimKI/fyped Name Signature Y <br /> r <br /> EPA Form 8700-22(Rev.1-05) Previous editions are obsolete: <br />