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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) a J1110 IN N"1" Form Approved.OMB No.2050-0039
<br /> UNIFORM HAZARDOUS 1.Generator ID Number 12.Pagelof 3,FmergerxyRespense Phone 4.Manifest Tracking Number
<br /> WASTE MANSFEST rot nrnrre�7�nr Tc Q'L I FLE
<br /> 5,Ge-Fatcr's Name and Mailing Address GenaVlotsi Slta Ackiress(if different than mailing address)
<br /> Dollar General#13592
<br /> 2098008820 310 W DR MARTIN LUTHER KING JR
<br /> Generator's Phone: CZTnCWTnm ra 5 —1 C
<br /> 6.Transporter 1 Gompany Name U.S.EPA 0 Number
<br /> C ,a a, t T i
<br /> 7.Trarrxpo�ar� yName ,9 E F urntiegr
<br /> 8 Designated Faculty Name and Sitff Address 21st Century EMN, LLC U.S.EPA ID Number
<br /> 2095 Newlands Dr. East
<br /> Fernley, NV 89408
<br /> Fadlit es Phone•
<br /> 9a. gb.U.S.bb perm(i uuding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.T=1201 12.Unit 13.Waste Codes
<br /> HM and Packing Group(if any)}
<br /> No. Typo Quantity WtNol.
<br /> X bN1993, Waste Flammable liquids, n. o.s. 1 DM 00043 P 331 D001
<br /> (Alcohol), 3, PG II, ERG#128
<br /> W
<br /> Ly X 6N1950, Waste Aerosols, flammable 2. 1, DDT-SP- 1 BA 00028 P 331 D001
<br /> 11296, ERG#126
<br /> 3.
<br /> X UN3266, Waste Corrosive Liquid, Basic, 1 GF 00035 P 122 DO02
<br /> Inorganic, N.O.S. (Sodium Hydroxide,
<br /> n111y,
<br /> v---a ata al,`.r r-raarrrJ E-\
<br /> X UN2810, Waste Toxic, liquids, organic, n.o. s. 3 DM 00353 P 331 Y3005
<br /> (Barium, Permethrin), 5. 1, PG II, ERG#153
<br /> 14.Special Handling Instructions and Additional Information
<br /> 1.110518(Flammable.Liquids - Loosepack) 2,PKG-DF:
<br /> 110541 (Aerosols) 3. 110515(Basic Liquids, Inorganic - Loosepack) 4. 110527(Taxic Liquids -
<br /> Loosepack)
<br /> 15. GENERATOR'SIOFFFROR'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 international and national governmental regulations.If export shipment and f am the Primary
<br /> Exporter,I certify Out the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent.
<br /> 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.
<br /> �,I55 nn ,pea Naamme //�/�/j Monm ay ear
<br /> -1 W I I Arte I rtn �n�r
<br /> -J 16.Intemli3tionalShipments/
<br /> I-- Import to U.SO ❑Export from U.S port ofx
<br /> Transporter signature(for exports only): Date 1e U .:
<br /> W 17.TranworterAcknoWedgment of Receipt of Materials
<br /> Transporter 1 Printadl{yped Name Ssgrialure Month Day Year
<br /> r1 Tis A Ainv.nti of I I ora I no Leh4 r
<br /> Z ran 2 Pm yped Narr Te
<br /> a
<br /> c IILI Sr Illi I I
<br /> 18.Discrepancy T1
<br /> 18a.Disaepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection
<br /> Manifest Reference Number.
<br /> 18b Altemate Facility(or Generator) U.S.EPA ID Number
<br /> J_
<br /> Facility's Phone:
<br /> U 18c.Signature of Alternate Facility(or Generator) Month Day Year
<br /> a x
<br /> Z I I I I.
<br /> r0—n 19.Hazardous Waste Ppport Management Method Codes(Le.,,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> UJ
<br /> 20.Designated bac lity Owner or Operator Certification of receipt of hazardous materials covered by the manifest e;cepptt as noted in Item 1(/8a
<br /> P mtedrryped Name t Signature Month Day Yew
<br /> 14
<br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNA ACILITY TO DESTINATION STATE(IF REQUIRED)
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