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Please int or Form designed for use on elite(12-pitch)typewriter) 1111111IN11111 Form Approved.OMB No.2050-0039 r �' type ( 9 ( P )tyP ) Fo PP UNIFORM HAZARDOUS 1 Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C,AL000371993 1 1 87757726E I 010177315 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Dollar General #13357 Dollar General#1:1357 2092531664 1201 WEST MAIN! STREET 1201 WEST MAIN STREET Generator's Phone: RIPON, CA 95366-312127I RIPON, CA 95366-30227 6.Transporter 1 Company Name U S.EPA ID Number Stgricycie Specialty Waste Solutions Inc I MNS000110924 7.Transporter pany Name U.S.EPA ID Number 8.DesignateU Weility Name and Site Address 21st Century EMN, LLC U.S EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 (y�'7�❑(] Facili f'sPhone: 77 7 2 7 I NVD980895338 ga 9b.U.S.DOT Description(including 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 Wt./Vol c X 1.UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 BA 00015 P 33 D00' w X 2'UN3266, Waste Corrosive Liquid, Basic, 2 BA 00046; 12 Inorganic, N.O.S. (Sodium Hydroxide, Potassium Hydroxide), 8, PG II, ERG#154 X 3.UN1993, Waste Flammable liquids, n. o. s. 1 CF 000161 P 3,3 . 1 (Alcohol), 3, PG II, ERG#128 4. 14.Special Handling Instructions and Additional Information 1.PKG—DF:110541 (Ae r o s o 1 s) 2.PKG—CF: 1 10515(Basic Liquids, Inorganic — Loosepack) 3. 110518(Flammable Liquids — Loosepack.) 15 GENERATOR'SIOFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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. Genera sl s Mts y Name / SignaPUTH Month Day Year i I 1 q 2127117 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter siqnature(for exports only). Date leavinq U.S.. LU 17.Transporter Acknowledgment of Receipt of Materials f / Transporter 1 Printed(fyped Name li,rtat Month Day Year a Jeff Hamilton I 0 1 14 2017 Z Transporter 2 Print ype a e Montin Day Year 18.Discrepan, 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: LO I& Signature of Alternate Facility(or Generator) Month Day Year Z 19.Hazardous WasteReportManagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 I2 3 4 20.Designated Facility owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted`in Item 18a` p y Signature Month DayYear s ,/ EPA Form 8700-22(Rev.7105) Prev—iouls editions arVobsolete. J 3ESIGNrD FA ILITY TO DESTINATION ST TE(IF REdAE 8700-22_12v3 CAL20072032 541053271 040960754 M )DII19117 SD111017