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i t I �III1�11�1� <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST "AR000278318 l 1 8775772669 005888174 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar General #13592 Dc;1 at I�erter a!#1:%5':i <br /> 2098008820 310 W DR MARTIN LUTHER KING JR 310 W DR MARTIN LUTHER KING .JR <br /> Generator's Phone: STOCKTON, CA 95806-1763 STOCKTON, CA 95206-1763 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stet-icyc a Specialty Wy_te Solljtjorr_ Irc MNS00011r3'.+ + <br /> 7.Trerx;porter 2 Company Na e � U.S.EPA ID Number <br /> 8.Desrated Facility Name and Site A re 21st 'ent ury EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands D-. Ea_t <br /> Fernley, NV 89408 <br /> Facill r'sPhone. 7755752760 I NVI)9808953.2 <br /> 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. , waste Bypocrilorite 5o utions 8, CF 00004 P 122 D002 <br /> 0 111, ERG#15A <br /> R <br /> LU <br /> z X 2.111N1'il waste Aerosols, flammable 2. 1, ERG#126 2 CF 00025 P 331 D001 <br /> ra <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 1 117351 r(8l each, Liquid) ?. 110541 (Aerosols) <br /> 15 GENERATOR'510FFERGR'5 CERTIFICATION: I bmt;y 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 labeledlplararded,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 EPA Acknowledgment 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 s41I quantity generator)is true. <br /> Gen rs Printed/Typed Name ,.(� g Month ay rear <br /> 067"410 L I 1 051 16 201 <br /> .International Shipments ILI <br /> H Import to U.S. ❑Export fro U.S. Port ofentry/e <br /> Z Transporter signature(for exports only): Date leavin. .S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials 1 177 7 <br /> Transporter 1 Printed/Typed Name gnature Month Day Year <br /> N <br /> Anthony Mask 1011 051 161201 <br /> Z Transpor9er2 me �// n�sefe Mon Day Year <br /> ro . <br /> 18.Discrepancy iI <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejectionj <br /> Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) US EPA ID Number <br /> J_ <br /> V <br /> LL Facility's Phone: <br /> C <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 I <br /> D <br /> 2Hj(� I 3. I4. <br /> 20.Desrgnated Facility Owner or Operator Certification of receipt of haj�rdqus materials covered by the manifest except a�need in tem 18a <br /> Printed/Typed Name '/�1ra <br /> ' ( \ '/� ' 1Signature tD 00 <br /> EPA Form 8700-22(Rev.3-05) Previous leddiitions are obsolete.f DE5 ATEr IT DESTI'd;112151618 <br /> STATE(IF RE°lbiRPI); <br /> 5700-22 12v3 CAL20072032„d 541053278 041102358 M PD051618 <br />