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FormApproved.OMB No,20'50-0039 <br /> Please print or type, <br /> UNIFORM HAZARDOUS 1.GerefaV ID Number 2,Page 11 3.Emergency ResponslPhone 9, ifest Tracking NumFmr <br /> WASTE MANIFEST CAR000278318 it 1 877577'566 347 FLE <br /> 5,Gpneralor's Name and Matistng Address Generator's Site Address(d different than malling address) <br /> Dollar General #13392 Dollar General#13592 <br /> 2098008820 310 W DR MARTIN LUTHER KING JR 310 W DR MARTIN LUTHER KING JR <br /> Generators phom STOCKTON, CA 95206-1763 STOCKTON, CA .95206-17613 <br /> 6.Trans,—Ac!I Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNS000110924 <br /> 7.Imispecter 2 Company Name U.S-EPA 10 Number <br /> 6L/'v&DW 06- k-e62V&-ty SY57EtIS --7--':7 4/ <br /> 6.Designated FacgilyNlame and Site Address Yuma Yes, LLG U.S.EPA 10 Number <br /> 2730 E. 13th Street <br /> Yuma, AZ 85365 <br /> Frjifty's Phone9286428938 AZR000515924 <br /> ga 9b,U.S.DOT Description occluding Proper Shpping Nan Hazard Class.fD Nut r, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> H,&,l and Pac*mg Gioop(ifanytl No, Type Quantity W�'ftl, <br /> Non RCRA hazardous waste, liquid (Consumer 2 DF 00268 P 331 � <br /> Products), -- -------- ------------- <br /> 3, <br /> 4. <br /> 14 Special Handling Instructions and Additional Inforinabon 1, 11052*4 N o n—RCRA L i q u i d Waste (CA Only) Loosepack) <br /> 15, GENERATORSIOFFEROWS CERTIFICATION:I hereby declare that the contents of INS consignment are fully and accuratpiy described above by the proper shipprriq rime,and are class€W,WIMle-J, <br /> marked and laboleftlacarded,and we in aij raspeM in proper condition for transport according to applicable international and national governmental regulations.If export shipment ON I am the Primary <br /> Exporter,I certify that the contents of this conitgntrient conform to the terms of the attached EPA Acknowledgment of Consent. <br /> l eerily that ft waste minimization statement identified in 40 CFR 262,27(a)(d I am a tar"quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generaito�ejjOfferor's Printed/Typed Name Signature Month Day Year <br /> "'It f->,<'rw k--, 'f;i- <br /> 16.International Shipments <br /> 1:1 import to U.S. LJ Export I'forn U.S. porl of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> cV 17.Transporter AcknovAedgment of Receipt of Materials <br /> Ce <br /> LU <br /> t— Transporter I PriMedlTyped Name Signature Month Day Year <br /> ---------- <br /> 0 Isidro Martinez 101 09 12 LO <br /> Tram 5 let 2 Pfinted/Typed Name Month Day Year <br /> eft,Ctfsctepancy Vk <br /> 18a,Cisclepa.%,/Indication Space ovartfiFJ <br /> Lt ty Type Residue ElPartial Reialtion Full Rejection <br /> Manifest Reference Number <br /> - <br /> I eb,Aftematet FacMy(or Generator) US,EPA to Number <br /> U- F-acf1ity's phone: <br /> 18c.Signature ofAllemate Facility(or Generator) RAantM Day Year <br /> 19.Hi;a(dopsWaste Report Managernent Method Codes Q.0,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> 20, - nated 1`2zhly prier or Operates:Certifical'ii2e of receipt of hazardous matenals covered by the manifest except as noted 19 item 18.,/. <br /> :1 ) � V <br /> ITTILOjo LCA,� Iq Ally <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsoli. DESIGNATED OkCILITY TO EPA's v i <br />