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1 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFOR�GAL@010137312174 <br /> tor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTi 8775772559 013124 5 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #13532 Dollar General#13532 <br /> 2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD <br /> Generator's Phone: STOCKTON, CA 95205-2926 STOCKTON CA 95205-2925 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNSOOO11092.4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address General Environmental Mgt, LLC U.S.EPA ID Number <br /> 11855 White Rock Road <br /> 16 gIgAg Rancho Cordova, CA 95742 <br /> Facility's Phone: <br /> 9a 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 /> o X 6N1950, Waste Aerosols, flammable 2. 1, ERG#125 1 CF 00004 P 331 D001 <br /> z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1. 110541(Aerosols) <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 intemationaland 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)(ifI am a small quantity generator)is true. <br /> Generator's/Offerors Printedr;r ed Name Signature �A4se4Ir--Day Year <br /> ��� It 20 612111 <br /> 16.International Shipments <br /> F- Import to U.S. El Export f6U_.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> a Jared Marciei <br /> zTransporter 2 Printed(ryped Name nature Month Day Year- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18 <br /> � Pdn�dffyped Name Sin thYe <br /> �AFan 8700-22(Rev.12-17) Previous edlbons are obsolete. D NATED FACILITY-To EPA's e-MANII1S1 SYSTO <br />