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Please print or type, (Form designed for use on elite (12 -pitch) typewriter.) Fnrm Gnnrnvari nKAR Nn XQLAnU trA rorm ofvu-zz (rev. a-uo) rrevious ep¢tons are ooso>I - t DESIGNATED FACILITW DESTINATION STAT- ('.F REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2- Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST I CA 00Q1373 74 1 18775772669012039575 F L E 5- Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General #13632 Dollar General#13638 2098008944 8907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generator's Phone: STOCKTON, CA 95205-2926 I STOCKTON, CA 95205-2926 6. Transporter 1 Company Name U.S. EPA ID Number Stericycle Specialty Waste Solutions Inc IMNS000110924 7. Tranprter 2 Comp ny Name U.S. EPA ID Number Fi O�f�vt ct 'fig �"'o� ►�'1©�d�a3-�' 8. Designated Facility Name and Site Address 21st Century EMN, LLC U S. EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facili f's Phone, 77551752760 NVD980895338 ga, 9b. U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers11. Total 12. Unit HM and Packing Group (if any)) Quantity Wt.Nol. 13. Waste Codes No Type X 1 , Waste Flammable liquids, n. o. s. _._-4 1 MW 00108 P 331 DO01 o (Alcohol), 3, PG II, ERG#128 W X UN1791, Waste Hypochlorite Solutions 8, PG 1 DF 00110 P 122 D002 III, ERG#154 X 41N2810, Waste Toxic, liquids, organic, n.o.s. 1 CF 00001 P 331 D005 (Barium, Permethrin), 6,1, PG II, ERG#153 4. TT Special Handling Instructions and Additional Information 1. 110518 (Flammable Liquids - Loosepack) 2. 110517(Bleach, Liquid) 3.110527(Toxic Liquids - Loosepack) 15. GENERATOR'S✓*FFEROR'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 labelediplacarded, 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 geneLatorAr (b) (if I am a small quantity generalor) is true. sNa 416/A��A brgna Month Day Year 08 24 Y-1 I 201�trraHoral " ' F_ Shona v L1Importto U.S. ❑ Export from U.. Port of entry/exit: Z TrsrisporlersrlaWre ler Xpft only): Date leavinq U.S-. W 17. Transporter Acknowledgment of Receipt of Materials �2 Transporter 1 PrintedlTyped Name Signature Month Day Year a Melissa Ballard 1 1 081 241201 2 Trans rter 2 P - ted/Ty d Name r- Month Day Year 12" 1121 l 18. Discrepancy / 18a. Discrepancy Indication Space ❑ Quantity 1:1 Type El Residue ❑Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J S r+ Facility's Phone: ` LU 18c. Signature of Alternate Facility (or Generator) "' Month Day Year z I I 19. Hazardous Waste Report Management Method Codes (Le,, codes for hazardous waste treatment, disposal, and recycling systems) UJ 1 2. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Ty Name \ Signature Month, Day Year trA rorm ofvu-zz (rev. a-uo) rrevious ep¢tons are ooso>I - t DESIGNATED FACILITW DESTINATION STAT- ('.F REQUIRED)