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Pleas 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 Tracking Number WASTE MANIFEST I CAL000373076 I 1 I 8775772669 010177309 FLE 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Dollar General #13592 Dollar General#171592 2098008820 310 W DR MARTIN LUTHER KING JR 310 W DR MARTIN LUTHER KING JR Generator's Phone: STOCKTON, CA 95206-1763 I STOCKTON, CA 95206-1763 6-Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Saltations Inc MNS000110924 7 Transporter 2 Co y ame U.S-E ID Number 8-Designated Facility Name and Site Address 21st Century EMN, LLC 'U.S.EPA ID Numbe 2095 Newlands Dr. East Fernley, NV &9408 Facil:'sPhone: 7755752760 NVD980895338 9a. gb.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 Wt.Nol. 13 Waste Codes X1. UN1950, Waste Aerosols, flammable 2. 1, ERG#12( i BA 00029 P 331 D00: 0 � X 2. UN3266, Waste Corrosive Liquid, Basic, i AA 00018 P 1 _ D002 o Inorganic, N.O.S. (Sodium Hydroxide, Potassium Hydroxide), 8, PG II, ERG#154 X 3. UN1993, Waste Flammable liquids, n. o. s. 1 CF 00001 P 33 D001 (Alcohol), 3, PG II, ERG#128 4, 14.Special Handling Instructions and Additional Information 1.PKG—DF:110541 (Aerosols) 2.PKG—CF:110515(Pa s i c Liquids, Inorganic — Loosepack) 3. 110518(Flamnable Liquids — Loosepack) 15 GENERATOW&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. Generators/utteror's Rmeorryped Name Signature momn Day Year X( T-VqGvt _S 1 I 1 I 1 q 2017 16.Intema al Shi nts � ❑Import to U S L1 Export from U.$, entrylexit: Transporter siqnature(for exports only)' /D'ilaving U.S.: 17 Transporter Acknowledgment of Receipt of Materials Ar Transporter 1 Printed/Typed Nameignature Monthay Year COL Jeff Ham�'.l�on I T 1 14 11 2017 Trdnsporler 2el Name oF th ay Year 18.Disgefancy t 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U I Facility's Phone: Wire.Slgnsixm of Alternate Facility(or Generator) Month Day Year Z I y19.Hazardous Waste Report`Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyclingsystems) � 1 2 I314. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pr yped Name Signature Month Day Year EPA Form 9700- (Rev.3-0 ) Previous editions are obsolete. v DESIG ED ACILITY TO DESTINATION STATE(IF RE,,bUIRED) 8700-2212V3 CAL20072032 541053278 0409607515 M PDIII017 SD111017