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` ? I'1I1"I��1 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No,2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number WASTE MANIFEST CAI i =7-•z. ,q 010 91245 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if difterent than mailing address) Dollar General #K13592 Do11a} (-ienerIal#17;59ti 2sZr9S�lr �?82k'� 310 W DR MARTIN LUTHER KING JR ;10 (.I DR MARTIN LUTHER I.INt JR Generator's Phone: S7JCKTON, CFI 95206 1763 STOCKTON, CA 95206-1763 6.1 ransporter 1 ompany Name U.S.EPA ID Number Ste -ii._ycle Specialty Waste Solutions Inc MNSI[Ik11h11O':-�--4 T Traci spOrtea 2 Company Name U.S.EPA ID Number ails 12, �c3 i 5. ePsighated acility Name an ite Address —ist CentC .S.EPA ID Numb&r >= �tr'y E'1�N, LLC 2095 Newlands l0r. East Pprn 1.ey, NV 89408 Facts s Phone: 775.-75E-:"760 7 .-7 ` 7b 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity wtivol. 13.Waste Codes m X 1 UN32(_•S, Waste Corrosive L-i uid Basic o q s s 1 -e,— 0""32 F 122 D0&; H Inorganic, N.O.S. (Sodium Hydroxide, ' Potassium Hydroxide), B, Pb II, ERG#154 (�I w X 2.UN1950, Waste Aerosols, flammable 2. 1, ERG#i2E I "ESA Q-1001716 P 33' D0@1' cU t X 3UN1655, Waste Nicotine Compounds, Solid N.O,S. i GF' 0000i P 311 P07`t (Nicotine), E:. 1, PG II, ERG#151 4. i 14.Special Handling Instructions and Additional Information ._.- _ 1. 1105i l(Basic Liqu).ds, inorc_tnic — Loosecaack) E`.PKG—DF: 110541 (AerosDIs) 3. 11124522(Nicot ifie isulf/PatcihesJ 15, GENERATOR'S/OFFEROR'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, 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 EPA Acknowledgment 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. Genera ero nl yped Name ignatureonth Day Year k f}„,a,%. 2jixs I i-� 21 2017 J 18- a wral ents Z El to U.S. ❑Export from U- Port ofentry/exit: _ Tr der;' tura(for exports only): Date leaving U.S.: w 17. ransportAcknowledgment of Receipt of Materials n ' TransporterrintedlTyped Nam. Month Day ear CL Jeff Hamilton ii c`( 2L711 7 Z Transpoft2 PrinWa Srgnatu Month Day Year 18 Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type y El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: Lu 18c-Signature of Alternate Facility(or Generator) Month Day Year z us19.Hazardous Waste/Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ p 1 41--Z 2. 3 � 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name � I Signature � Month lay Year / I� lot l 6 l Ik EPA Form 87y00-22(Rev.3-05) Previous editions are obsolete. ! DESIGNATED FACILITY TO DESTINATION STATE(IF RE[UIRED) R7I[0—G. '12v3 _ S 2 3 C _ CAL,7��tD7s.�:-tr' S�I.1�J?r7r ±(r}f7iQ9SEesF? 11'( pt T11;_�,�°2 i,7 •gin 1 2�':�{7