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Please print or type.(Form designed for use on elite12- itch <br /> ( Pitch) ERIN Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number T2P1 <br /> ge 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANfFEST CAL000373076 8009246804 008664884 FL E <br /> 5.Generators Name and Ma ling Address Generator's Site Address((different than mailing address) <br /> Dollar General#13592 <br /> .,2098009820 310 W DR KARTIN LUTHER KING JR <br /> Generators Phone: STOCKTON -CA 95206-1763 <br /> mnsporter Fampany area <br /> U.S.EPA IQ Number <br /> " Zteric cle Speci.alty Waste 5alutions Inc hfNS000110924 <br /> 7.Transpo r2 Name <br /> U.S.EPA 10 Number <br /> C1'w4`r S� G# f 7 <br /> S.Designated FactlityName sltaAddness General Environaent 1 Mgt, LLC U.S.EPA ID Number <br /> 11855 White-.Rack Road <br /> Rancho Cordova, CA 95742 <br /> Faoli s Phone:.916351$980 <br /> 0884 .93 <br /> 9a. 9b,U.S.DOT Descr ption(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit <br /> No. Type Quantity Wtivol, <br /> 13.Waste Codes <br /> ,r X 1•UN1791, Waste Hypochlorite Salutians 8, PG 1 DF0013$ P i2i D002 <br /> .III, ERG#154 <br /> LU <br /> w 2- an CRA ha-zardous waste, liquid (CDnsuoer 2 DF 00289 P 331 <br /> Products), <br /> 3. <br /> a. <br /> 10.Special Handling Instructions and Additional Intornl ykIn 1 each, i q u 1 d, Non—RCRA Liquid Waste <br /> Only) •- Loosepack) (CA <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:i hereby dedam that the contents of this oon4nment are tufty and eocuratety described above by the proper shippirg name,and are wed,pec aged, <br /> marked and IabeledVaarded.and are in as respects in proper condition for transport socordug to applicable o�tematiorel and national govemmanta! <br /> Exporter,l certify'he'the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. regtAatlors.If export shipment and I am ft Primary <br /> I certify that the waste minimization statement idenffW in 40 CFR 26237(a),(d I am a large quantity generator)or(b)(d I�n a s quantity generator)is true, <br /> ame g�V1 U <br /> :nT,eras <br /> 09 22 201 <br /> lmpet to U.S. ❑Export from U.S. of en*e,;dtre on : <br /> 17.TransporterAcgwwl*rnent of Receipt of Materials leavi U.S.: <br /> Transporter I PninWyped Name <br /> ram. Kri_sto her Alranza y �n <br /> T er 2 PrintedrTyped Name 0g -.22 P.01 .. <br /> g� oath ay ear. . <br /> 18. 4 <br /> lea.Discrepancy Indication Space U Quantity ❑Type <br /> ❑Residue ❑Partial Rejeetion ❑Full Rejection <br /> 18b,Alternate Facility(or Generator) Manifest Reference Nr4nber <br /> -� U.S.EPA 10 Number <br /> U <br /> r+Q- Faali Phone: <br /> 0 18c.S gnalure of Alternate Faakty(or(.ienerate) <br /> z Mash Day Year <br /> st <br /> w 19.Hazardous Waste Repot Management Method Codes(i.e..codes for hazardous waste treatment disposal,and recydkv syr ) <br /> 0 1 ( 2. 3. <br /> d. <br /> 20.Designated Facility Oym¢r a Operator Certificstiah of receipt of hazardois materials covered by the rnarhitest ext <br /> PrintedrTyped Marne except as rated in Item f <br /> S Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editiom are obsolete. / <br /> ti MATED FACILITY'TO DESTINATION STATE(IF REQUIRED) <br />