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Please print or type. (Form designed for use on elite (12 -Ditch) tvoewriter.l Form Aooroved. OMB No. 2050-0039
<br />DESIGNATED ow ii rfy Tn DESTiuATLnu STATE (!F acro l REE#
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<br />UNIFORM HAZARDOUS
<br />1. Generator ID Number
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<br />2. Page 1 of
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<br />3. Emergency Response Phone 4. Manifest Trackin Number
<br />01 Q 8 5 515 F L E
<br />WASTE MANIFEST
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<br />7 77
<br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
<br />0o1lar-.Genera1.#13632 Dollar General#13632
<br />2098008944_ 2907.E. WATERL00 ROAD" 2907 E. WATERLOG ROAD
<br />Generators Phone: 5T(XKTON - CA 95205-2926TOCKT9N —
<br />6. Transporter 1 Company Name U.S. EPA ID Number
<br />Stericvcle Saecialty Waste Solutions Inc!MNS00011911324
<br />7. Transporter 2 Company Name U.S. EPA ID Number
<br />J, 9� 33
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<br />8. Designated Facility Name and Site Address U.S EPA ID Number
<br />_ General Environmental.Mg.t, LLC, .
<br />11855 White Rock Road
<br />Rancho Cord,n:va, .GA .957.42:
<br />Facilit}'s Phone: q 11 1 LUSM_.;
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<br />gb U.S. DOT Description (including Proper Shipping Name, Hazard Gass, 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 (rf any))
<br />Quantity
<br />WtNol.
<br />> X
<br />'UU993j---.(r)a8t! Flammable ;.liquids,
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<br />331
<br />D0011.
<br />(Alcohol), 3, PG II, ERG#128
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<br />2tA+1 950,,. -.Waste -Aerosols, flammable ,2. 1, ERG#126
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<br />00016
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<br />331
<br />D001<
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<br />X
<br />3UW3266, Waste Corrosive Liquid, Basic,
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<br />CF
<br />00008
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<br />122
<br />D002
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<br />IorBan�i.c�, :. N.•E?.:5; :.tSadiva;..Hydr. ax�idl, �,. , :: ...
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<br />1 W077, ::Waste nv ranagntaLly hazardous = ,
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<br />00001:
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<br />181
<br />D009
<br />substances, solid, n. o. s. (Mercury, Broken
<br />14.SpectalHandlirglnstriictionsandAdditionallrifamation _i: s,i��a�'l��tltl.a. L�ii��fr�-. Loosepaek? �. ,•2;111�54i (Alrgsa,., :� `
<br />110515(Basic Liquids, Inorganic - Loosepack) 4.110544(Mercury Containing Waste (Broken
<br />F3.uorascent.,4.-Lasp),)
<br />15. GENERATOR'ti/OFMOR'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 intemational 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 terns of the attached EPAAclmoWedgment 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 />Printed/Typed Name re Monet ay ear
<br />VneratorsiLmerors
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<br />16. Intemational Shipments u,
<br />❑ Import to U.S. ❑ Export from U.S. Port
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<br />of entry/exit: _
<br />Transporter signature (for exports only): Date leaving U.S.:
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<br />17 Transporter Adm wledgment of Receipt of Materials
<br />Transporter 1 Printedffyped Name SignaLr Morm My Tw--
<br />Transporter2Printed/TypedName��� A� Month Day Year /
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<br />18. Discrepancy v
<br />189. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection
<br />Manifest Reference Number:
<br />tab. Alternate Facility (or Generator) U.S. EPA 16 Number
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<br />Atemate Facility (or Generator)Month Day Ye*,
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<br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)LU
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<br />?a. t]esig>isted Faciity Owner or Operator. Certification of receiptd hazardous materials covered by the manifest except as noted in Item 18a
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<br />Signature 11 y yew
<br />V �l a CCS./ V[/ I I:_
<br />Fnrm R7fSr1_�9 rRnv 4x1 0�
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<br />DESIGNATED ow ii rfy Tn DESTiuATLnu STATE (!F acro l REE#
<br />,w
<br />870� -cc 12:x3 CALM72G132 gA11 �7r, : n,3nwt 4 t M es�an}, -r �r+�a�Z rt 7
<br />i4 z
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