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Please' 'nt or Form des' <br /> Pn ( designed for use on elite(12 pitch)typewrites) *. Form Approved.OMB No.20M.0039 <br /> UNIFORM HAZARDOUS J 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phdne 4,M"Iest Tracking Number <br /> WASTE MANIFEST CALO0$373076 11 18775772669 1 , 008680689 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different rf mailing address) <br /> Dollar General #1359 : Dol ar General#13592 <br /> `�— <br /> 209810108820 310 W DR MARTIN LUTHER KING JR 3102 W DR MARTIN LUTHER KING JR <br /> V era>o�sPhorrer. STOCKTON. CA 95206-176'3 STOCKTON. CA 9521216-1763 . <br /> DIJ Mer 1 Company Name U.S-EPA ID Number <br /> �QStpricycle 5necialty Waste Solutions In I iNNS fill' .=k <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Sj►lAddress General Environmental Mgt, CLC U.S.EPA ID Number <br /> 11855 White Rack Roan <br /> -T1 Rancho Cordova, CA 35742 <br /> FaciliVs Phone. 9163 0980 Iri4nq 068418:3 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12. <br /> HM and Packing Group(if any)) No. TM Quantity WL/Vol.Unit Unit 13.Waste Codes <br /> O ',Non RCRA hazardous waste, solid (Consumer �, DF Qu444 P331 <br /> Products), <br /> W 2. <br /> C3 <br /> 3. <br /> 4 <br /> 14,Special Handling Instructions and Additional Information 1, 1 1052 9(Non—RCRA—Solid Waste (CA Only) — Loose perk) <br /> 15. RENERATOR'SMFFFROR'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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Consent. <br /> I. 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. <br /> Wyped me ],Month y e-ar <br /> -j . nts �q �f�, {'I 121 161201€ <br /> ❑import to U.S. ❑Export from U.S. Port of entry/exit: <br /> T+�55� <br /> onl Date leaving U.S.: t (/ <br /> W 17- rRecAipl,ofMateria� Tran <br /> _ Month ay sal <br /> a Kristopher Alsanza M�—= <br /> a1 z Pdntadrryped Name 1 12 16 211€ <br /> Monthay Ycar <br /> 18.DiscrepaKcy <br /> 17; <br /> I El 16a.Discrepancy Indication Space Quantity ❑Type ❑Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> IS 18b,Ahemale Facility(orGeneralor) i3er�en�Number; <br /> U.S-EPA 10 Number <br /> U <br /> K <br /> >L Fed! s Plane: <br /> W 1&- oFNbmate FaaEtiy(er Ger erafor) <br /> U"oM Day Year <br /> 7g-Hazardous YYasta Report INanaperrrerd Method Codes(l.e.,oodes far hoz n1XZ waOe"3trtWL disposal,and <br /> 2- <br /> red sting sysbns) <br /> x <br /> a 4. <br /> 20.Designased Fanyily Owner or OperaW Certifrca of rac*l of hara*w malenals covered bythe mat�tlesE except as noted in!tern <br /> Hato <br /> EPA form 87 22(Rey,3.135) Prevfour editivea are obsolete Z- <br /> DESIGNATED FACI![TY TO DESTIkATIUN oil <br />