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Please print or type. 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 riall A77577PAAr 013124016 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Dollar General #13632 Dollar General#13632 2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generator's Phone: STOCKTON CA 95205-292 `—r r 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 21 st Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. o X 6N3266, Waste Corrosive Liquid, Basic, 1 CF 00015 P 122 D002 Q Inorganic, N.O.S. (Sodium Hydroxide, C LU X 6N3077, Waste Environmentally hazardous i CF 00011 P 181 D009 substances, solid, n. o. s. (Mercury, Broken 3. 4. 14.Special Handling Instructions and Additional Information 1. 110515(Basic Liquids, Inorganic — Loosepack) 2. 110544(Mercury Containing Waste (Broken Fluorescent Lamp) ) 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 labeledlplacarded,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 PrintedlTyped Name Signature Mo Year l 120 019 _j 1 16.Interna icnal Shipments P Import to U.S. Export from U.S. Port ry/exit: F ? Transporter signature(for exports only): Date leaving U.S.: a' 17.Transporter Acknowledgment of Receipt of Materials Day W portMonth Da Year r— Transer 1 Printed/Typed Name Signature a Jared Marciel it 20 019 Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U rai Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year ZZ N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LIJ 1 1410 2 11+/ 3 T 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM 8700-22 12v3 CAL20072032 S41053276 041597662 M PD112019 SD112019