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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 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 CAR000278325 1 18775772669 005888046 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dollar, General #13357 Dollar- General#133,51 <br /> 2092531664 1201 WEST MAIN STREET 1201 WEST MAIN STREET <br /> Generator's Phone: RIPON,, CA 95366-3027 I RIPON, CA 95366-3027 <br /> 6 Transporter 1 Company Name U.S EPA ID Number <br /> Stericycle Specialty Waste Solution_ Inc MNS 001i0y24 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8-Designated Facility Name and Site Address c: s 6 Lenl;Lwy LPIN, LLL, U.S-EPA ID Number <br /> 2095 Newland- Dr. East <br /> Fernley, NV 89408 <br /> Facility's Phone- 7755752760 NVD980895338 <br /> ga 9b U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11-Total 12.Unit <br /> 13.Waste Godes <br /> HM and Packing Group(if any)) No, Type Quantity wt.Nol. <br /> —T7QN17%j1, Wase Hypochlorite Solutions 8, 1 CF 00018 P 122 D002 <br /> o Ill. ERG#154 <br /> W2. 1 , asGe Herosols, annan e , li P 331 D001 <br /> c� <br /> 3- <br /> 4. <br /> 14 Special Handling Instructions and Additional Information 1. 110 1 ( each, Liquid) 2. 110541 (Aerosols) <br /> 15. GENPRATOR'61OFFEROWS 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 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 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 /> GTwOMWs PrinWypad Name Month Day Year <br /> 1 041 06 1201E <br /> J isInWrrrafttil Shipments <br /> z 11Import to U.S. ❑Export it U.S. Port of entrylexI _ <br /> Tr(rispadar S Irxe for expom only): Datilea4ng i <br /> ce 17.Transporter Acknowledgment of Receipt of Materials ' <br /> Transporter 1 Printed/Typed Name Signalr Month Day Year <br /> CO Anthony Mack I 1 041 061201' <br /> QTransporter 2 Printed/Typed Name _ SignaNrrW Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑ I Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S EPA ID Number <br /> J_ <br /> 0 <br /> LL Facility's Phone: <br /> w 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Z I I <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ� 1 I2 � - I3. I4. <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed+Typed NameBON <br /> t� I Signature Amnll- <br /> EPA <br /> Form 8700-22(Rev.3-05) Previous a tions are obsolete. \\ LSIG'uATED FACILIT T DESTINATION STATE(IF REQUIRED) <br /> 8700-22 12v3 CAL20072032 S41053271 041076680 M P0040618 SD040618 <br />