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1 1 <br /> Please p rtt or type.(Form designed for use on elite(12-pitch) writer. <br /> typewriter,) Form Approved.OMB No.2050-0039 <br /> UWIFORM HAZARDws 11`Generator ID Number 2.Page 1 of 3. Respatsa Phona 4 Manifest Tracking Number <br /> WASTE ih1AMFEST CAL000373076 1 I B/5772659 010177308 F L E <br /> 5.Generators Name and Mailing Address Generator's Site A&IFess(ff different than mailing address) <br /> Dollar General #13592 Dollar 13eneral#135` 2 <br /> 2098008820 310 W DR MARTIN LUTHER KING JR 310 W DR #MARTIN LUTHER KING JR <br /> GeneralnrsPlttrne: STOCKTON, CA 95206-1763 STOCKTON, CA 95206-176: <br /> ansporter t ompany ame U.S.EPA ID Number <br /> jLn Stericycle Specialty Waste Solutions Inc MNS@00110924 <br /> T.Transporter 2 Company Name <br /> i U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address beneral Environmental Mgt, LLG �U.S.EPA IDNumber <br /> 11855 White Rock Road <br /> Rancho Cordova, CA C 742 <br /> F (s Plane: 9163510980 CAD980884183 <br /> ga, 9b:U.S.DOT Description(including Proper Shipping Name,Hazard Class,fD Number, 10,Containers 11.Total <br /> MM and Packing.Group(rf any)) No. Type Quantity 1 12.2,Unit Unit 13.Waste Codes <br /> -din hazardous Waste, solid (Consuser I V1- <br /> Products), <br /> atProducts), <br /> 2. Pion RCRA hazardous waste,—liquid lquid ( 'onsuser d Ut urweltt <br /> I� d „SS r <br /> Products), <br /> 3 <br /> n. <br /> 14.Special Handling Instructions and Additional Information 1. 110529(Non-RCF Solid Wa 5 t e (CA Only) - L o o s e pa ck) 2. <br /> 110524(Non--RCRA Liquid Waste (CA Only) - Loosepack) <br /> 15. MERMTOR'%0FFM W'8 CERTRCATfQN: 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 temis of the attached:EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if f am a large quantity generator)or(b)(•rf I am a small gtlaniity generator)is true. <br /> r-Aneraf&SiOflemes Priakd7yVeVNarne Signature Month ay ear <br /> lkr, �i�l�rnL C �, ' E, 1 14 2017 <br /> �. 1:lntelMflondIShipments ' <br /> Import to U.S. ❑Export from U.5 / <br /> T signature(for exports only): <br /> 17.Truer Acknowledgment of Receipt of-Materials <br /> Transporter 1 Printed/Typed Name Signa ren f Month Day Year <br /> a Jeff Hamilton ' 1 14 j 7 <br /> ,Z Transporter 2 PrirdedrtypeC Name <br /> SignalGMont ay ear <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Re ection <br /> 1 ❑Full Rejection <br /> 18b Alternate Facility(or Generator) Man lest Reference Number: <br /> U.S.EPA ID Number <br /> U <br /> a <br /> Fad 5 Brttxrea <br /> 1 Bc.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i-e.,codes for hazardous waste treatment,disposal,and recycling syslerr1s)LLI <br /> I <br /> 2. q/ 3. <br /> 4 <br /> 4m870 <br /> Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nosed in Item 18a I <br /> Signature <br /> Month Day year <br /> l <br /> a5] Pre�iiaus editions are obsolete. SIGNATED FACILITY TO DESTINATION STATE OF REQUIRED) <br />