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111111111111111 Please print or type. Form Approved. OMB No. 2050•0039 EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM A700 -22.12v3 CAL20072032 S41.05327A _n4130?977 M PnO11?41q RD01P4tq UNIFORM HAZARDOUS 1. Generator ID Number I 2. Page 1 ofr'.77577.485888 11 Emergency Response Phone 4. Manliest Trackin Numbrar F L E WASTE MANIFEST CAL000373074 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General #13632 Dollar General#13632 20980089+4 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generators Phone: STOCKTON CA 95205-2926 STOCKT 95: 05-29PA 6. Transporter 1 Company Name U.S EPA IC Number Stericvcle S ecialty Waste Solutions -Inc 7. Transporter 2 Company Name U.S. EPA ID Number ...�- . 2' 8. Designated Facility Name and Site Address 21st Century EMN, LLC U.S. EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Fa' cility's Phone: 77�iS7�P7 l Q A ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. X "UN1950, Waste Aerosols, flammable 2.1, ERG#126 1 BA 00011 P 331 D001 0 �a its LU X 2'UN1993, Waste Flammable liquids, n.o.s. 1 CF 00002 P 331 D001 0 (Alcohol), 3, PG I1, ERG#128 X 3-UN1479, Waste Oxidizing solid, n.o.s. 1 CF 00001 P 181 D001 (Hydrogen Peroxide, Sodium Hypochlorite), 5. 1 PG II ERG#140 4. 14. Special Handling Instructions and Additional Information 1. PKG-DF ;110541 ( Aerosols) 2. 110518 (F 1 am m a b 1 e Liquids - Loosepack) 3.110526(Oxidizers, Solid, Inorganic - Loosepack) 15. GEIIMT6R'8MFFER0WS CERTFXATl0W I hereby dedare that the conbents of this oo oinnerd are fully and aco alely descdbed by N proper shipping name, art! are dassrfed, packaged, marked and la AkWpiacarded, and ere in WrespeGs kr pamper oorndilion far transport aarordnp to apptical* International and national ental regulations- If export shipment and i am the Primary EWoder, i ow* that the eantents o1 this amignment =* m to the tams of the attached EPA Ackrimlerlgrnent of Consent. m hrilzatlon statement Were fled in 40 CFR 21TUT(a) (d I am a large quanilly generator) or (b) (-dl am mall q rrelatvr) i5 true. i oertify Ysm the warmn Generatorted7Typed N me Signature Month Day Year + 101 16. InternoMal hip its ❑ Import to U.S. ❑ Export from U.S. Port of ntry/exit: ? Transporter signature (for exports only): aving U.S.; igg 17. Transporter Acknowledgment of Receipt of Materials A Transporter 1 Pdrited/Typed Name Signature �j Month Day Year �f(L/ 7ef iltnn I oil PAJ awl Trarw Y med Name SlgnaLure Monntth� DayYear I 18, Discrepancy 18a. Discrepancy indication Space ❑ Quantity ❑ Type ❑ ❑ Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U I Facility's Phone W Ik, Signature of Alternate Facility (or Generator) Month Day Year z H19. Hazardous Waste Report Management Method Codes (Le,, codes for hazardous waste treatment, disposal, and recycling systems) LLI\ � 1I2I3 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/ryped Name signahue Month Day Year 1191 EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM A700 -22.12v3 CAL20072032 S41.05327A _n4130?977 M PnO11?41q RD01P4tq