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r <br />Phaco print nr tvna <br />i <br />Form Approved. OMB No. 2050-0039 <br />N <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />013124016 F L E <br />WASTE MANIFEST <br />5 <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Dollar General #13632 Dollar General#13632 <br />2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD <br />Generator's Phone: STOCKTON CA 95205-292 `—r r <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />. <br />5 " k yn C14l,>S e 3 ,9, 5 <br />8. Designated Facility Name and Site Address 21 st Century EMN, LLC U.S. EPA ID Number <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />Facility's Phone: <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />X <br />6N3266, Waste Corrosive Liquid, Basic, <br />1 <br />CF <br />00015 <br />P <br />122 D002 <br />o <br />Q <br />Inorganic, N.O.S. (Sodium Hydroxide, <br />C <br />LU <br />X <br />6N3077, Waste Environmentally hazardous <br />i <br />CF <br />00011 <br />P <br />181 D009 <br />substances, solid, n.o.s. (Mercury, Broken <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 1. 110515 (Ba s i e Liquids, Inorganic — Loose pack) 2. 11$544 ( Mercury <br />Containing Waste (Broken Fluorescent Lamp)) <br />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, <br />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 <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 />Generator's/Offeror's PrintedlTyped Name Signature Mo Year <br />l 120 019 <br />_j <br />16. International Shipments P <br />Import to U.S. Export from U.S. Port ry/exit: <br />F <br />? <br />1 Transporter signature (for exports only): Date leaving U.S.: <br />a' <br />17. Transporter Acknowledgment of Receipt of Materials <br />W <br />r— <br />Month Da Year <br />Transporter 1 Printed/Typed Name Signature y <br />a <br />Jared Marciel it 20 019 <br />Z <br />Transporter 2 Printed/Typed Name Signature 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 />U <br />rai <br />Facility's Phone: Month Day Year <br />W 18c. Signature of Alternate Facility (or Generator) <br />ZZ <br />N19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LIJ1 <br />G 4. <br />/4l Q-1 2 11+/ 3 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Month Day Year <br />Printed/Typed Name Signature <br />P Lut f I l % I <br />nCCrP_AI ATCn CA('11 ITV TO r-DA°c a_PUIx1NIPPRT SYSTEM <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are oosoiere. <br />UL.Jl illm I - s r-wed� r <br />8700-22 12v3 CAL20072032 541053276 041597662 M PD112019 SD112019 <br />