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Please prin 'Pe.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000373074 1 8775772669 010788838 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #13638 Dollar General#13632 <br /> 2098008944 2907 E. WATERLOO ROAD 0907 E. WATERLOO ROAD <br /> Generator's Phone: STOCKTON CA 95205-2906 STOCKTON CA 95005-2926 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Steric cle Specialty Waste Solutions Inc M <br /> 7.Transporter 2 Com ame U.S.EVA lj)�k b <br /> 8.Designated Fa6ity Name and ite ddress Rho Chem, LLC jn I T� G� U.S.EPA ID Number <br /> 425 Isis Avenue <br /> Inglewood, CA 90301 <br /> Facility's Phone: 3237766233 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1 Non RCRA hazardous waste, solid (Consumer 1 DF 00040 P 33 <br /> 0 Products), I <br /> Z 2- Non RCRA hazardous waste, liquid (Consumer 1 DF 00072 P 331 <br /> LU <br /> Products), s� _...n...,. _....... <br /> 3. <br /> 1 <br /> 4. <br /> Ll 1 <br /> 14.Special Handling Instructions and Additional Information 1. 110529(Non—RCRA Solid Waste (CA Only) — Loose pack) 2. <br /> 110524(Non—RCRA Liquid Waste (CA Only) — Loosepack) <br /> 15. GENERATOR'S/OFFEROR'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 all 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 terms of the attached EPA Acknowledgment of Consent. <br /> 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. <br /> ator's/Offeror's Printed/Typed Name i ure Month Uay ear <br /> 1Z-�aWl Z 7 <br /> j Mftematio6al Shipments <br /> F 1:1Import to U.S. El Export from U.S. Port ofentry/exit: <br /> Z Transporter signature for exports only): Date leaving U.S.: <br /> W 17,Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 PrintedlTyped Nameignatur Monthay Year <br /> a JohnnyHar r 20117 <br /> Z Transporter 2 Print ed a Signa r Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp <br /> ❑T e ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) t CG/ f^ � (� U.S.EPA ID Number <br /> �- <br /> Facility's Phone: 0 v <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> Lj <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF RE')UIRED) <br /> A7012-PP _t?v3__t'.01 P"7 I717=+ - -qAI AFi-X:17A. - f14,1Ag7'`XJ7I7 IM - - -- -- Dni::-a717- RIl1:PrA71 7 <br />