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f r531C 1� Please print or tvoe. (.Form designed for use on elite f 1 ?-nBnhl r„p,-ifpr UtSIGtNAI EU FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 14. Manifest Tracking Number WASTE MANIFEST CAL000373074 1 8775772869 f 010788838 F L E 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General #13832 Dollar General#1363 2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAR Generator's Phone: STOCKTON CA 95205-2926 STOCKTON CA 95205-2926 pa 6. Transporter 1 Comny Name U.S. EPA ID Number Steric cle Specialty Waste Solutions Inc MNS000110,327. Transporter 2 Com ame U.S. E 8. Designated F i ity T4ame and ite "dress Rho Chem, LLC '/1 �T- U.S. EPA ID Number 425 Isis Avenue Inglewood, CA 90301 Facility's Phone: 3237766233 - ga 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)) Quantity Wt.Nol. 13. Waste Codes No. Type 1.hlon RCRA hazardous waste, solid (Consumer 1 DF 00040 P 33 Products), UJ w 2-Nlon RCRA hazardous waste, liquid (Consumer 1 DF 00072 P 33 PraduLts), 3. 4. 14. Special Handling Instructions and Add itionalInformation 1.110529(Non-RCRA Solid Waste (CA Only) - Loosepack) 2. 110524(Non-RCRA Liquid Waste (CA Only) - Loosepack) 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. ator's/Offeror's PrintedlTyped Name i ure Month Day ear �QQS -j tomational Shipments7 ❑ Import to U.S. ElExport from U.S. Port of entry/exit: - Transporter signature for exports only):Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Namegnatur Month ay Year O a_ JohnnyHar r Transporter 2 Print ed a 14 04 POW! 7 Signa r Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b. Alternate Facility (or Generator) / /� 'f C U.S. EPA ID Number Q Facility's Phone: 0 %� G t/ w 18c. Si=becility (or Generator) Month a Day Year ZLdz�vf r in -19. Haz ase port Management Me od Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1. 2. // 3. 4. 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 =PA Form 8700-22 (Rev. 3-05) Previous editions ora nhsnlpfp UtSIGtNAI EU FACILITY TO DESTINATION STATE (IF REQUIRED)