COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) E Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000373076 1 1AM0924660, 1008664884 F L E 5.Generator's Name and Wing Address Generator's Site Address(tt different than mailing address) Dollar General#13592 .12098008820 310 W DR MARTIN. LUTHER KING 3R GeneratoesPhone: STOCKTON. •CA 95206-1763 Transporter l Company Name U.S.EPA IG Number " stericycle Specialty Waste Solutions Inc MNS000110924 . 1.TmnVortr 2 C4tapsny Name U.S.EPA ID Number Cry SAF Gam, 11g1 LXP t 7 B.DesitnatedFacility Nameinord'119Address General Environment9l Mgt, LLC U.S.EPA ID Number 11855 White—Rock Road Rancho Cordova, CA 95742 Fad +s Phone:.9163510980 D980884 83 9a• 9b.U.S.OOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WiNol. Cr X 1•UN1791, Waste Hypochlorite Solutions 8, Pe 1 DF 00138 P 12' D002 III, ERG#154 w 2.Non RCRA hazardous waste, liquid (Consucer 2 DF 00299 P 331 Products), 3. 4. 14.Special Handling Instructions and Additional Information 1-111azittbieachll Liquid) 2. 110524(Non—RCRA Liquid Waste- (CA Only) — Loosepack) 15. fiENERATOR'510 FFEROR'S CERTIFICATION:I hereby declare that the contents of this consgnment are Ally and aaeatety described above by the proper shipping name,and are dassifisd,packaged, marked and labeiedtptacarded.and are in all respects in proper Condition for transport ac w*Q to applicable international and nawnat governmental regulations.K export shipment and b am the Primary Exporter,I cw*that the contents of this oonsirnrent oWorm to the terms of the attached EPA ACImov4iedgment of Consent. I cerllfy that the waste minimization statement identified in 40 CFR 282.27(a)(d I am a large quantity generator)or(b)(d t am a sgWl quanlity generator?is true. i �1 PdCir 0 scr �Name 'r9Y Year LZ 12 wz , 091 22 201 i _j 18.In ❑Import to U.S. ❑Export from U.S. of entrylextt• T lure kx"Puts only): leavintl U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PwbDdrTyped Name mom 0ay Year a Kristopher Alranza f y _ _•��,09) .22�201 zd T r 2 yAed 1Yarne gre Maim Uay year. 119 l :,�Ilcl sa. 18a.asorepan y Indication Space L) Quangty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejacdion Manliest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number v L Faalitys Phone: 18c.Signature of Ahemate Facady(or Generator) Month Day Year z 19.Hazardous Waste Repod Manages dM Method Codes(i.e.,codes for hazardous waste treatment,disposal,and reclrding systems) G1, l 2. Oitt_1 ) l3 I4. !. 20.Designated Facility Qwner or Operator.Certification of receipt of hazardous materiats covered by the maMest except as noted in Item iaa Pnnta6gyped Name Signature Month I Day Year I I EPA Form 8700.22(Rev.3-05) Previous edilJorls are obsolete, DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)