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Please piiApe. (Form designed for use on elite (12 -pitch) typewriter.) IN IN 1111 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REI)UIRED) A7 2:PP_-t:PvX.-17.al ?AA7?LA-2 P -- Sla1 M=.XP711 _.. n/A91g7=jA017 - M -. - --. - Dn1 Pa71 7- CRn11 PIGA71 7 UNIFORM HAZARSous 1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking 4umbo WASTE MANIFEST CAL000373074 1 I 8775772669 I 010788838 F L E 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General #13638 Dollar General#13632 2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generators Phone STOCKTON. CA 95205-2926 STOCKTON. CA 95:205-2926 Transporter 1 Company Name U.S. EPA ID Number Stericvcle Specialty Waste Solutions Inc MNSI2101171110q24 7. Transporter 2 Com arae / 12 8. Designated Fadifty Name and SiteAddress Rho Chem, LLC jn I `t' ,%1 �y U.S. EPA ID Number 425 Isis Avenue Inglewood, CA 90301 Facility's Phone. 3237766233 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.Nol. 1 -Non, RCRA hazardous waste, solid (Consumer 1 DE 00040 P 33 Products), ,Wz„ 2 -Non RCRA hazardous waste, liquid (Consumer 1 DF 00072 P 33 Products), 3. 4. 14. Special Handling instructions and Additional information 1. 110529(Non-RCRA Solid Waste (CA Only_) - Loosen_ ack) 2. 110524(Non-RCRA Liquid Waste (CA Only) - Loosepack) 15, GEMERAMIT&OFFEROR'8 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. 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. hIcertify e s ure Month ay Year I T.�.��L / ( I 1 VIPot 1 —j. r temational Shipments ❑ Import to U.S. ❑ Export from U.S. U Port of entry/exit Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Namenatu Month ay Year a I Johnny Haral_r . I I 1R 04 PAt Z Transporter Print _ / na Month Day Year E'_IV� �- 18 Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) p Ce f Em n L C U.S. EPA ID Number G ��s S`7 s a100 , �� Q Y& V1 ��3 D �t 8 u- Facility's Phone: OY, n S'�"� 0 W 18c Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes ffoor hazardous treatment, disposal, and recycling systems) LU 0 1 �,L�, }waste 2 I� 1. 1 1( 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a 71yped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REI)UIRED) A7 2:PP_-t:PvX.-17.al ?AA7?LA-2 P -- Sla1 M=.XP711 _.. n/A91g7=jA017 - M -. - --. - Dn1 Pa71 7- CRn11 PIGA71 7