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111111111111111 Form Approved,ONIB No.2050.0039 <br /> Please print or type. --- ponsephone <br /> T17C;;neAox ID—Number of 3.Emergency Re -P <br /> UN <br /> C 000, f;Q91 97PLE <br /> UNIFORM HAZARDOUS 3 '3 pale (877) :577-2:6:69 ni i <br /> Number <br /> WASTE MANIFEST CAL01210369845 <br /> 5,Ge6erwors Name and Mat"Address Generators Site AMmalting address) <br /> 99 Cents Only #177 99 Cents Only#177 <br /> (209) 956-4992 1120 E. Hamner Lane 1120 E. Hammer Lane <br /> Generators Phone: Stockton- CA 95210 Stockton, CA 95210 <br /> U.S.F PA io Number <br /> 6 Transporter I Comparit Nam <br /> Stericycle Specialty Taste Solutions Inc MNS000110924 <br /> -T- U.S.EPA ID Nurnber <br /> Transporter 2 Company Name <br /> A k47 CJ ....... <br /> fl.Gee ed Facilityress Yuma, Yes, LLL <br /> Narm�nd to US,EPA iD Number <br /> 2730 E. 13th Street <br /> F.94 Is None:9286428938 Yuma, AZ 85365 AZR000515924 <br /> 98' 94.U.S.DOT Description(including Proper shipping Name,Huard Class,ID Number, io,Containers 11,TOW 12.Unit 13,Waste codes <br /> HM and P--*irV C-T- (ti W�) No, Type- 0"* WtNol, <br /> I Non RCRA hazardous waste, liquid (Consumer 2 CF 00024 P 331 <br /> 0:! --- <br /> Products), <br /> Z 2. <br /> LU <br /> 3, <br /> C <br /> 14,special Handling Instructions and Additional 00—fion 1. 10199@(CA State Regulated Liquids) <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and amratePi desoilbed thou*by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper coWition for transport acoording to applicable internalionaf and riational governmental regulations.H Mod sNprrierit and I am the primary <br /> Exporter,I certify that the contents of this consignment con1writ to the terms.of the SPAchad EPA Acknowledgment of Consent. <br /> I certify that M waste minimization statement WentfW in 40 CFR 262,27(a)(If I am a large quantity generator)or(b)(KI am a small quantity generator)is true <br /> Generfmverol's PrinWyped Name signature adehaof 93- en Only Month Day Year <br /> M4a(L�C'j� P lf 1 <br /> rZ,rk L 23 201 0" <br /> 16.tntemiational Shpments <br /> El trnw to us ❑Export from U.S. Pon of entrVexft: <br /> ?,TranspotTer signature(W exports only): Date leaving U.S.: <br /> W !7,Trantpoder Acknowledgment of Rva*� of Materials <br /> Uj 1-i <br /> Tr Signature <br /> dmwdef I PrmtedrNara me Wnhh Day year <br /> Demarco Brodnax -2 <br /> zz201 <br /> - <br /> z i ransporter 2 P"e0yped Nam Sig tu writh Day year <br /> g f\ a, vT!LL--f/2 <br /> 7, 10 <br /> 18.Discrepancy �Ii <br /> I18a,Discrepancy tridica6ori Spew Quantity ❑Type FIResidua El Pahl.)Reject. Full Rejection <br /> Manifest Reference Number: <br /> tab.Alternate Factity(or Generator) U.S.EPA ID Number <br /> Fa atitys Phom- <br /> in Mc Day Year <br /> W 180.Signature of Afternate Facility(or Generator) <br /> !a <br /> Z <br /> 19,Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste traatmer=t disposal,and racycling systems) <br /> tu <br /> 20.Designated Facility Owner pj Operator,Certification of receipt of hazardous materials covered by the manifest exceA as noted in l 18a <br /> Pfirited,7yped Name Sit;natUM7 <br /> T "h Day Year <br /> �q U. <br /> EPA Form 87D0.22Previous editions ari"61:isolete. !GMTED FACILITY TO ERA's e-MANIFEST SYSTEM <br />