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.Please Dn?4 or tvoe. (Form desioned for use on elite (12 -Ditch) tvmew ler.) Form ADoroved. OMB No. 2050.0039 <br />tNA horn) 61UV-ZZ (Kev 3-Ub) Nreviuus eamonS are oD501eie. / <br />8700-2212Y3 CAL20072032 S41053276 040975607 M <br />DESIGNATEDiFAG(LITY TO DESTINATION STATE (IF REQUIRED) <br />PD120717 SD120717 <br />r <br />T <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />2. Page 1 of 3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />I <br />I 010 7 8 8 8 3 9 F L E <br />rai ulmm 74 <br />1 A77977PAAq <br />5. Generator's 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 />Co,eratoris Phone: ST T N CQ T ro Q'iPMR—PCIPA <br />6. Transporter 1 Company Name U.S EPA ID Number <br />_qteriewelp SpecialtyWaZtg Spicitions TnL- <br />7. Transporter 2 Name U.S. EPA ID Number <br />8. DesignaW Facility Name and Site Address 21st Century EMN, LLC U.S. EPA ID Nunflber <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />Faciltt Is Phone: 77c;R757 A IS-Ao <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No, <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />X1 <br />UN1993, Waste Flammable liquids, n.o.s. <br />1 <br />CF <br />00006 <br />P <br />33 <br />D00J <br />(Alcohol), 3, PG II, ERG#128 <br />X <br />z. UN1950, Waste Aerosols, flammable 2. 1, ERG#12E <br />1 <br />CF <br />00007 <br />P <br />33:. <br />D00 <br />. <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />1. 110518(F1amlwable Liquids — Laosepack) 2.110541 (Aerosols) <br />15. GENERATOR'&ZIFFEROR'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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />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 small quantity generator) is true. <br />Oftors PrintecUTyped Name r on ay Year <br />F- <br />1 ationA Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leavinq U.S. <br />LU <br />17 TransporterAcknowledgment of Receipt of Materials o <br />Transporter 1 Printed/Typed Name Signature onth Day Year <br />a <br />Johnnv Har. mw <br />z <br />Transporter 2 PnntadlT a gnetu Month uay Year <br />// <br />�}r <br />/ <br />18. Discrepancy <br />18a. Discrepancy Indication Space y ❑ Type ❑ ❑ I ❑ Full Rejection <br />Quantity T e Residue Partial Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />v <br />LL <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />I <br />19. Hazardous Waste Report Method Codes (i.e , codes for treatment, disposal, and recycling systems) <br />Management <br />`hazardous `waste <br />20. Designated Facility Owner or Operator: Certification of receipt of hazar us matanal covered by the manifest except as noted In Item 18a <br />Printed/Typed Name Signature Mont D Year <br />tNA horn) 61UV-ZZ (Kev 3-Ub) Nreviuus eamonS are oD501eie. / <br />8700-2212Y3 CAL20072032 S41053276 040975607 M <br />DESIGNATEDiFAG(LITY TO DESTINATION STATE (IF REQUIRED) <br />PD120717 SD120717 <br />r <br />T <br />