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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 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1 2.CAR000278325 1 1 1 8775778669 011386863 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#13357 <br /> 092531664 1201 WEST MAIN STREET 1201 WEST MAIN STREET <br /> Generator's Phone: RIPON, CA 95366-3027 RIPON, CA 95366-3027 <br /> 6-Transporter 1 Company Name U S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc 1 MNS000110924 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> c!►lt.rc S �rI 3 <br /> 8.Designated Facility Nam SL century U.S EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> FacilitrsPhone- 7755752760 NVD980895338 <br /> ga, gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol- <br /> o X 1-UN1993, Waste Flammable liquids, n. o. s. 1 CF 00005 P 331 D001 <br /> (Alcohol), 3, PG II, ERG#128 <br /> X 2UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 DF 00035 P 331 D001 <br /> X 3-UN1791, Waste Hypochlorite Solutions 8, PG 1 DF 00037 P 122 D002 <br /> III, ERG#154 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 110518(Fla■■able Liquids — L o o s e pac k) 2. 110541(Aerosols) 3. <br /> 110517(Bleach, Liquid) <br /> 15. GENERATGR'SPOFFERgR'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 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 /> Generatoes/Offerorsrinted/Typed Name Signature montri Day Year <br /> -j 16 International Shipments <br /> t— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports ontv): Date leaving U.S-: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name SigmhZe montri Day Year <br /> w <br /> I �� 1 011 191201 <br /> a .farad Marri al <br /> Transporter 2 Printed/Typed Name signature month Day Year <br /> ~ 1 1 <br /> 18.Discrepancy " <br /> 1Be.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 1 <br /> v <br /> Ll <br /> LL Facies 's Phone: <br /> W I Signature of Alternate Facility(or Generator) Month Day Year <br /> a 1 I I <br /> Z <br /> H19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> H ISI 12, �1 ISI 1 13 H iT 1 14. <br /> II20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name WVVC, O,!� L 1 suture p r�M� /�� I Month 1 1 a2-1 Year <br /> I EPA Form 8700-22(Rev.3-05) Previoui editions are obsolete. r/�'!) `DESIGNAI/TED CILI TO QESTINATION STATE(IF REQUIRED) <br /> 8700-22 -12v3 CAL20072032 541053271 041008003 M 11918 SDO11918 <br />