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Please print or type.(Form designed for use on elite12- i
<br /> ( p tch)typewriter.) Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Mantfmt Tracking Nomher
<br /> WASTE MANIFEST I CAL1600373076 1 8775772668 I 010685516 F L E
<br /> 5.Generator's Name and,Mai ng Address Uenerwa Site Address(if different than mailing address)
<br /> Dollar. General #13532 Dollar General#13592
<br /> 2098008880 310 W .DR MARTIN LUTHER KING JR 310 W DR MARTIN LUTHER KING JR
<br /> Generators Phone: STOCKTON ;CA, 95206-1763 STOCKTON CA 95206-1763 .
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> Stericvcle Seocialty Waste Solutions Inc MN110924
<br /> 7.Trarhsportaf 2 Company Name `tet, ii U.S.EPA ID Number
<br /> X Jll///f, fn '
<br /> 8.DeV oted adfrty Name and Ste Address ' –
<br /> General 'Environmental Mgt, LLC., ' U.S,EPA to Number
<br /> 11855 White Rock Road
<br /> Rancho,,Cordo;va,.-CA 95742_:,
<br /> F. Ing: 9i'6 351.098
<br /> 9b.U S_DOT (including Proper Shipping ,
<br /> Sa. ��( m9 Pe rpping Name,Hazard Class,ID Number, •
<br /> HM attl Padding�p(fi any)) 10.Containers 11 Total 12.Unit
<br /> No. Type Quantity Wt.Nol. 13.Waste Codes
<br /> 10 77, Waste Env irons.entai'l y ;hazardous, . 1 CF ,.. . (dOr�81;- . P ;. - .181 D8109 .
<br /> - substances, solid, n.a.s. (Mercury, Broken
<br /> e
<br /> X , Waste Corrosive Liquid, Basic, 1 CF
<br /> ' _; 00007..,...< .P� � ..12E,•I)002 .. ,;_
<br /> Inorganic, N.O.S... (Sod.iUm-Hydrox de*
<br /> Potassiullll H droxide). 8. RG II. ERG#154
<br /> )L 3tN+i1950,,.-:Waste,�erasols,.; flasaahl 1, ZR1,.;.:ERN126 >_ 1 r: CF,
<br /> 4Non RCRA hazardous waste, liquid (Consumer 1 -
<br /> DF 01145 P 331
<br /> 14.SPerxal a
<br /> Handlingnlehi Woos rr6llddlthaha! _
<br /> . .. , .1,.L1044.(Mercury.,Containing;.Wast. -(Broken FIv"scent lamp):) 2.,:
<br /> 1.19315(Bas c Liquids, Inorganic_ — Loosepack) 3. 11054.1(Aerosols) -4. 119Wj+(Non—RCRA Liquid
<br /> 'Waste .{ICA1.�1y)�•,— Loclsepatck�}�:,
<br /> 15. GENERATORWO OFFEROR'S CERTIRCATION: I hereby declare that the contents of this consignment are fully and accurate) described above b the
<br /> Y Y proper Shipping name;and are dam th
<br /> marked and habefedlplacarded,and are m all respects it Proper condition for transport according to applicable international and national govemmerital regulations.t e
<br /> xport
<br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowl edgment of Consent. sh p nent and I am the Primary
<br /> I c&*that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantitygenoreti7r)or(b)('d I am a small quantity
<br /> brmufklroeaY>7ed me generator)is true.r gna re r..
<br /> morm
<br /> .j 18.International Shipments (}
<br /> ZImport to U.S. Export from U s Pori of entrylexit
<br /> Transporter sburture ffor exvorts Date tea' U'S.:
<br /> 17.Tr�rpporter AclTmAedgntal of Receipt of materials
<br /> Trarsporler 1 dnbdlT Name pature --
<br /> ., ,.. .—.. _� . .. �.
<br /> I Mnsporter 2 Pdnted/Typeil Name _._-- .23
<br /> nature sedMonth
<br /> K I ay
<br /> 18.Discrepancy
<br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejed. ❑Full RejecCmn
<br /> 18b.Atemate Fatty(or Gsnerebr) Re encs NumSer
<br /> =-� U.S.EPA ID Number
<br /> Ct
<br /> Ac
<br /> Fadi s Phone: ';
<br /> 78c.SigraErre of mate Fad'rY(or )
<br /> AMhrti Day YsAr
<br /> CJ W j19 Fta�ardous Waw
<br /> >�ePorl lhartx�emant Metrod r Odes(ke.,codes for hazardou3 W"tredtment,drgK .and "ftft)
<br /> 14, r J1
<br /> 20,t]esigrreted
<br /> �AU�—, -- frfd$r4wear ttiaon oempdtzadoma9riaa+ered the
<br /> eur�tasrhotsdin ��
<br /> r&Wa7rMRvfm22 ,
<br /> Pievious tIdttions are obsalets_ --
<br /> DESMATED FACIU Y TO'DESTIMAMN STATE(IF REWRED)
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