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W -% EPA Form $760-21 (R§v. 305) Previous etttW"rre ohscleMr— I- I __ _: �... -. ,.n. .-.�sn-.nn•sn nr-am-.n-�r r�inl+-rr��+., 1 *)I1JNAItUrA1,ILI1i lvu�.�l�►enllvlralncLto r��a,tvu.....� Please print or type. (Form designed for use on elite (12 -pitch) Form Approved OMB No. 2050 -0039 UNIFORM HAZARDOUS 1 Generator ID Number Page 1 of 1 3. Emergency Response Phone 4. Manifest Tracking Number 008553736 FL E WASTE MANIFEST CAL000373074 1@7757'12559 5. Generator's Name and Mailing Address Generator's Site Address (d different than mailing address) Dollar General #13532 Dollar General#13612 2098008gi-4 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generator'sPhoneA ( STOCKTON, CA 95205-2926 STOCKTON, CA 95205-2925 6. Transporter 1 Company Name U.S. EPA ID Number Stericycle Specialty Waste Solutions Inc I MNS000110924 7. Transporter 2 Company Name U -S. EPA ID Number 8. Designated Facility Name and Site Address General Environmental Mgt, LLC U.S. EPA ID Number 11855 White Rock Road Rancho Cordova, CA 95742 Faali �sPhone: 1153510980 I A111a41 A3 ga 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. X 1UN1950, Waste Aerosols, flammable 2.1, ERG#125 2 BA 00050 P 331 DO01 0 X 2UN1993, Waste Flammable liquids, n. o. s. 1 CF 00009 P 331 D001 (Alcohol), 3, PG II, ERG#128 X 3UN3077, Waste Environmentally hazardous 1 CF 00001 P 181 D009 substances, solid, n.o.s. (Mercury, Broken Fluorescent Li ht Tubes), 9 PG II -I. ERG#171 4Non RCRA hazardous waste, liquid (Consumer 2 DF 0.0271 P 331 .Products), 14. Special Handling Instructions and Additional Information 1. PKG-DF : 11 @541 ( Aerosols) 2. 110518 (F l a.m m abl e Liquids - Loosepack) 3.110544(Mercury Containing Waste (Broken Fluorescent L.amp)) 4.110524(Non- RCRA Liquid Waste (CA Only) - Loosepack) 15. GENERATOW&WFEROR'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, packajes marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. ff export shipment and I am the Prima 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 small quantity generator) is true. Generators/Offerors PrintedlTyped Name Month ay 06I, 281204 .j Z 1 . temational;;ly'pments ❑ Import to U.S- ❑ Export from U.S. Port of entrylexit: Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials L2 Transporter 1 Printedrryped Name Signature Month Day Year �, Isidro Martinez. _ L 061- 28-I;vI Q Transporter 2 Printed/Typed Name Signature Month Day ' Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b- Alternate Facility (or Generator) U.S. EPA ID Number V FaciliNs Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year I I I z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) C 7. 2. I3. 4. 20. Deslgnata r : Certification of r of 4ous covered bythe mant except as 1Se Prim me 1 *4 y ear n nr 1\ ATFl1\I i�TATC 11 f]Cr1 uor:ni EPA Form $760-21 (R§v. 305) Previous etttW"rre ohscleMr— I- I __ _: �... -. ,.n. .-.�sn-.nn•sn nr-am-.n-�r r�inl+-rr��+., 1 *)I1JNAItUrA1,ILI1i lvu�.�l�►enllvlralncLto r��a,tvu.....�