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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.2050.0039 <br /> r UNIFORM HAZARDOUS 1,Generara M Number 72Pag,1 of 3.Emergency Response Plane 4.Ma est Tracking NumberWASTE MANIFEST CAL00037199316775772669D1 1693l6 FLE <br /> 5.Generator s Name and Mating Address Generator's Site Address(if different than mailing address) : w <br /> Dollar General #13357 Dollar General#13357 <br /> 2092531664 120AWE$_T MA.J N-.STREET ___..__ 1201 WEST MAIN STREET— <br /> Generator's Phorfe I PON, CA 95366-3027 I RIPON, CA 95366-3027 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc IMNS000110924 <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> B.DesgnaledFacilityName and Site Address enera I Environmental Mgt, LLC (U.S.EPAIDNumber <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> FadR Phone_163510980 ICAD980884183 <br /> ga, I gb.U.S.DOT Desorption,(including Proper Shipping Name,Hazard Class,ID Number, 10.Conleitrera 11.Total 12.Unit <br /> HM and Packing Group(f any)) No. Type Quantity W.Unit 13.Waste Codes <br /> K JN1993, Waste Flammable liquids, n.o. s. 1 DM 00045 P 331 001 <br /> 0 (Alcohol), 3, PG II, ERG#128 <br /> w <br /> W K 3141950, Waste Aerosols, flammable 2. 1, ERG#126 1 CF 00009 P 331 D001 <br /> c� <br /> i <br /> Aon ?CRA hazardous waste, solid (Consumer <br /> }roducts), 1 DF 00078 P 331 <br /> don RCRA hazardous waste, liquid (Consumer 2 DF 00268 P 331 <br /> Droducts), <br /> 14.SpeclalHandlingkishKtivnsand Additional Information 1. 110518(Flammable Liquids - Loosepack) 2. 110541 (Aerosols) 3. <br /> 110529(Non-RCRA Solid Waste (CA Only) - Loosepack) 4. 110524(Non-RCRA Liquid Waste (CA <br /> lnly) - Loosepack) <br /> 15. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above byte proper shipping name,and are classified,packaged, <br /> marked and labeledrplarxrded,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 EPAAcknoMedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gerteralrr am a t quanbN generator)iswDi <br /> true. <br /> 19 Month r <br /> I107 1 06 X017 <br /> .1 16.IntematonalShtpment& <br /> z El Import to U.S. ❑Export from U.S. <br /> T lure(for exports only): Date leaving U.S.: <br /> W 17.TransporterAduwwledgmenlofReceipt ofMaterials <br /> E2 Transporter 1 PringWyped Name <br /> Month ay aar <br /> ZCL Phil Marciel 107 106 1@17 <br /> Transporter 2 Pmnledrfyped Name Signature Month y <br /> ~ I I I <br /> YOU <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑ <br /> Residue Partial Rejection Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. <br /> � U.S.EPA ID Number <br /> U <br /> I <br /> �- F s Phone: <br /> W1tk SignatureofAltemateFacility(arGenerator) <br /> Q Month Day Year <br /> 19.Hazardous Waste Report Marragemerrt Method Codes(i.e.,codes for hazardous waste treatment,di <br /> w r [ sposal,and recycling systems} <br /> 2. Wj�q 3 4 <br /> 1 <br /> d Farah Owner or OperaOor CargS�tion d Mc* <br /> Pd hazardous materials covered by the manifest except as noted in Item 18a <br /> � � Signature <br /> ay Year <br /> EPA Form 8700.22(Rev.3.05) Previous ediLlion'sVarel obsolete. <br /> AESIG ACIL TO D INATIOM STATE(IF REQUIRED) <br />