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Please print or type. (Form designed for use on elite (12 -pitch) tvoewriter.) Form Approved. OMB No. 2050-0039 8700-22 12v3 CAL20072032 S41053276 041072715 M PD032818 SD032818 UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3, Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST I CAL000373074 11 18775772669 I o 1 o 8 6 8 3 8 o F L E 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Dollar General #13632 Dollar General#13632 2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generator's Phone. STOCKTON, CA 95205-2926 STOCKTON, CA 95205-2926 6. Transporter 1 Company Name U.S. EPA ID Number Stericycle Specialty Waste Solations Inc MNSOOOII0924 7- Transporter 2 Company Name U,S. EPA ID Number 8. Designated Facility Name and Site Address 21st Century EMN, LLC U.S. EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facilit es Phone: 7755752760 NVD980895338 9a. 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.Nok X 1•UN1950, Waste Aerosols, flammable 2.1, ERG#126 1 CF 00012 P 331 D001 0 2.UN1 9 , Waste Flammable liquids, n. o. s. 1 CF 00007 P 331 D001 LUX 0 (Alcohol), 3, PG II, ERG#128 X 3UN3139, Waste Oxidizing liquid, n.o.s, 1 CF 00002 P 141 D001 (Hydrogen peroxide), 5.1, PG II, ERG#140 X 4•UN1791, Waste Hypochlorite Solutions 8, PG 1 CF 00009 P 122 D002, III, ERG#154 14. Special Handling Instructions and Additional Information 1.110541(Aerosols) 2. 110518(Flassable Liquids - Loosepack) 3. 110525(Oxidizers, Liquid - Loosepack) 4.110517(Aleach, Liquid) 15, GlENERATOR'SfOFrEROR'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 nation 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 q mtlty generator) Is true, P117 Name` 50211AW0 Monthay Year 1 031 28 1201 F of nal hiprAe l I ent y+l xi*. _ ❑ Import to U.S. ❑ Export from U. %Ite. Z Transporter signature (for exports only): av U.S.. W LLJ 17 Transporter Acknowledgment of Receipt of Materials I-- Transporter 1 PrintedfTyped Name Signature Month 11ay Year y Johnny Harper 1 1 031 2812011 Z Transporter2 Printed/Typed Printed/TypedName'ignature(, Month Day Year � -U�r I �1 119 I 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quanti77 ty ❑Type ❑Residue ❑Partial Rejection L1 Full Rejection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number J U uK FacilWs Phone: 1 W 1 ac, gignature of Alternate Facility (or Generator) Month Day Year z I I 1 h19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) ( / i 20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as not; in Item 17, Pint !Typed DameSignature Month Day Year ` 11/110 EPA Form'8700-22 (Rev. 3-05) PPev`ious editions are obsolete. I nFSlrvATl=n Fecu ITVArn n -nivATlnk! CTATF AF Drf it IIRFnt 8700-22 12v3 CAL20072032 S41053276 041072715 M PD032818 SD032818