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1 l ilEmiliooil <br /> Please print or type.(Form designed for use on elite(12-pitch)typewrites) ��{ y 7 �r1,i 1 yt Form Approved.OMB No 2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST .,;an7 I 1 1AMMQP/ArAMLs f 008664683 FLE <br /> 5.Generators Name and MailingAddress Generator's Site Address(it different than mailing address) <br /> -'Dollar General #213592 Dollar Generalt213592 <br /> 20981008see 3110 W OR MARTIN LUTHER KING JR 310 W DR MARTIN LUTHER KING JR <br /> Generata'sPhone, ST(1rKTf1N rA qr�rf3A-179-1 I c;TiI1rI/Tr1W_ r-a cici?IAF,-17A.2 <br /> r ti 1 ransporter 1 Company Name U.S.EPA ID Number <br /> Gterir_vl'le S.eCilitV WAste Snititions Ince 1AN.gyimmiIlTrq?4 <br /> 1 7.Transporter 2 rry Name U.S.EPA ID Number <br /> Q*ncQ,�i,lc,cwl7 <br /> y� 8.Designated Facility Nard and Site Address General Environ6bntal 14gts LLC U.S.EPA ID Number <br /> 11855 tdhite Rock Road <br /> Rancho Cordova, CA 95742 , <br /> Facifilyls Phone: 916351098(A I CAnq_ AA4 :4 <br /> 9a. , 9b.U.S.007 Description{including Proper Shipping Name,Hazard Class,lD Number, 10,Containers 11,Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> a <br /> '-Non RCRA hazardous waster liquid (Consucer a OF 00282 P 331 <br /> o Products), <br /> I � <br /> 2-Non HCRA hazardous waste, solid (Clrnsuaer 1 DF 00125 P 331 <br /> LU <br /> 0 Products), <br /> 3. <br /> i <br /> 4. <br /> 14,Special Handling tnsbuciions and Additional{nfom atian i.. 119524(Il o n--RCRA Liquid Waste (CA Un 1 y) - L o o s e p ac k) 2. <br /> 116:329(flan-RCRArSolid Waste (CA Only) - Laosepexk) <br /> 15. GENERATOR'SW EROR'5 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 label"placarded,and are in all respects in proper condition for transport according to applicable intemalional 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 EPA Acknowledgment of Consent. <br /> I certify that the waste mnimit �n statement identified in 4QCFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. <br /> e groes y ems } /� rgn tUre Month Day Year <br /> r <br /> {- lltr '! "(� { I1 � 041201f <br /> F !s. ehra8onal ❑Import,to U.S.? j j❑fxpo t from U.S. Port of entryfeidL• ` ). <br /> Z T r na only): Date leaving U.S. <br /> LU 17.Transporter Acknowledgment of Receipt N Materials <br /> Transporter 1 Printedfl`yped Name Signa urs Monty Day Year <br /> a Kristophpr Aloanza I I 11 041201f <br /> U)z Transporter 2 not yped Name Signature t on y ear <br /> 18.Discrgpancy ` <br /> 18a.Discrepancy Indication Space DuanS <br /> ty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. t <br /> 18b.Alternate Facility(or Generator) U-S.EPA ID Number <br /> Facilitys Phone. <br /> C3 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> H 19,Hazardous Waste Report Management Method Codes(i.e.,codes for h1Ll <br /> waste treatment,disposal,and recycling systems) <br /> 0 UJI ' <br /> 14 1L-1 I !2 I �! I3 I4 <br /> 20,Designatefi Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in I0(o 18a (/ /� <br /> ${ypuSd <br /> + 51,nature � MthYear <br /> PrintadName <br /> I DCJ <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. l \ J SIGiNATED FACILITY TO/GF./(IERATOR STATE(IF REQUIRED) <br />