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Please print or type. I Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST F L E rat _o 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 99 Cents Only #177 99 Cents Only#177 (209) 956-4992 1120 E. Hammer Lane 1120 E. Hammer Lane Generator's Phone: Stockton CA 95210 Stockton, 6.Transporter 1 Company Name U.S.EPA ID Number Steric cle Specialty Waste Solutions Inc MNS110100110924 7.Transporter 2 Company Name --,-/ s/�! ,, " f -1) __. _ U.S.rEPA ID Number a,X' 8.Designated Facility Name and Site Address 21 st Cent ury EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone:775575760 NVD980895338 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. X UN3077, Waste Environmentally hazardous 1 CF 00005 P 181 D009 o substances, solid, n. o. s. (Mercury), 9, PG III ERG#171 z 2. LU t7 3. 4. 14.Special Handling instructions and Additional Information 1. 101993(Broken Fluorescent Bulbs) 15. GENERATOR'SIOFFEROR'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, 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 Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed //v Typed Name /�` Signature On17alf O f 99 t s Only Month Day Year J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI� Transporter 1 Printed/Typed Name Signature Month Day Year a Demarco Brodnax -✓ ~ ' 1 081 2:31201 Z Transporter 2 Printed/Typed Name _� /✓ / Signature / Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1. �� 2. F 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed ped Name Z Signature � M h Da Year 1 8M0,0 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIG TED FACft1TY"f0 EPA's e-MANIFEST SYSTEM 8700-22_12v3 CAL40000139 540028263 041514398 M PD082319 SD082319