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Please print or type. , II� I��II�I )I�IIf�In� �I Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 9o Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST rQPO--.� �- _ - FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing a dress) Dollar General #13552 Dollar General#13592 2098008620 310 W DR MARTIN LUTHER KING JR 310 W DR MARTIN LUTHER KING JR Generator's Phone: r'c - ' c_ 6.Transporter 1 Company Name U.S. PAID Number 7.Transporter 2 ompU. . I um er any am 8.Designated Facility Name and Site Address 21St Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 8948 Facility's Phone: 779975P7A0 NVD9FQA95:7---;A 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 1 E UN3266, Waste Corrosive Liquid, Basic, 1 CF 00006 P 12 D0021 Inorganic, N.O.S. (Sodium Hydroxide, rHVHrnxJr-lP) , A. Pr, III FRG#i54 LU X 2UN3139, Waste Oxidizing liquid, n. o. s. 1 00103 Ir' 141 D001 (Hydrogen peroxide) , 5. 1, PG II, ERG#140 3Non RCRA hazardous waste, liquid (Consumer 2 331 Products), a 14.Special Handling Instructions and Additional Information 1. 110515i8asic Liquids, inorganic — Lovse(;a::x) �. 110525(Oxidizers, Liquid - Loosepack) 3. 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 EPAAcknowledgment 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 Printed/Typed Nam - Signature Sig n n 17 1 f f Month Day Year A PI 16.Internation ipments F- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ?I Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials r Transporter 1 Printed/Typed Name Signature Month Day Year O a Z Transporter 2 Printed(ryped Name S a Month Day Year F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: F 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z ca19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1 4/9� T 14o7V 3. 14/q-/ 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped Name ),/ � �� Signature f Month �y Year /rf71 4%l G C./ 4k4— (/sC,.�e, CS EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM