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Please print or type. Form Approved OMB No.205x_0%9 <br /> UNIFORM HAZARDIDuS I 1 Generator ID Number 2,Page 1 of 3-Emergency Response Phone4.Manifest Tracking Number <br /> WASTE MANIFEST r+pt AAA-7�A*7 A77�77?F.F.Q 1 012485887 F L E <br /> 5.Generahors 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 /> Generators Phone: RTnf'KTnm_ rix SCoTnruTnKi g4?Ac—?q?r <br /> 6.Transporter 1 Company Name US EPA ID Number <br /> Rt r+ir-urrl o Gnlrrftinna Tne MKIglAA1A1 1IAq24 <br /> 7.Trrrhspp*2 Company Name U.S.EPA ID Number <br /> 1W1 -mJ ��f�!V 1 /lav_YA �V I CeS; ICS (Lct A 251:2 <br /> S.Eles gr fed FaCMity Name and Site Address Rho Chem, LLC U.S.EPA ID Number <br /> 425 Isis Avenue <br /> Inglewood, CA 90301 <br /> Facility s Phone: 3237766233 <br /> ga 9b.U.S.DOT Desaiption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total, 12.Unit <br /> HM and Ping Group(dany)) 13.Waste Codes <br /> No. Type Quantity WtNol. <br /> X lt1N3266, Waste Corrosive Liquid, Basic, 1 BA 00008 P 12c D602 <br /> Inorganic, N.O.S. (Sodium Hydroxide, <br /> Potassium Hvdroxide). I PG II. ERG#15 <br /> Z 2. <br /> LU <br /> 0 <br /> 3. ._ <br /> 4. <br /> 14.Special,Handlirg lnstnictions and Additional lnfoin attar <br /> 1.PKG—CF:110515(Basic Liquids, Inorganic — Loosepack) <br /> 15. CaEMT(W91DFFMR'S L RTiFlCATiOH:t(hereby dedara that ahe oonlents of this consigrhtnerh[are.firlrY.and aaur plji;. "st!op@.J:Y the pflperaHFpi ,nafrra, a dassifed.Packaged, <br /> marked and labeleNplaimr4ed.and are n all respects in proper coMiflon for transport acmtdkV to appllcabfe w&matiord . . . ' I.repul@tierra.Vaig rl d4pment and I am the Primary <br /> Egwler,I aatlify that the Conlenis of ibis agnsgwsW COnfonn 10 ft.Wm of the alladied LPA 4ftrnerd Of Conserhk <br /> I certify that Che,Haste mine mzabon staternenl identified m 40 CFR 262.27(a)ff I am a large quanuly generator)or(b)rjjqim aE< WF Is Due, <br /> 'rdw YPVsgnabire -- - Month Day Year <br /> f <br /> 11711,11 ?4I ?A1 f <br /> Import to U.S. ❑Expat frofi U-S- Pat entrylexff <br /> Transport siwialura(tar Wports only). Date .avi[hg.u.S <br /> At-t- AdmowleAm met ofReceiptof Material s <br /> r r<nn <br /> Namg <br /> y Synafure MonthDay Year <br /> ff .Ha iZtort I I Ail ?4I ?A1 4 <br /> '�` Monfh Day Year <br /> - Quantity QType <br /> ❑Residue _ D Partial Rejection Full Rejection <br /> Manifest Reference.Number: <br /> U.S,EPA IQNumber' <br /> 186 <br /> t i <br /> ti Day Year <br /> e. p Mon(fi..., <br /> Zlk <br /> t A Is#*Codes(i.e.,cedeshazardous was <br /> for hazardte treatment,disposal,and recycling systems) <br /> Uj <br /> 4. <br /> a 1; 2. I _ <br /> 20; <br /> 0(ma j A of us materials covered by the mandegKxcept N notedTjq4jaa <br /> /� I S gr�ture <br /> F7lonsh kDal <br /> ta <br /> EPA Fa 1{ (Rev.12r17� Pre ._ :.rtivth5 are . �� / DESIGNATED FACILITY TO EPA's e�MANIFEt SYSTEM <br /> i <br />