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Ftease print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 i.Generator ID(dumber 2.Page i of 3.Emci ro Response Phone i 4,klanlfestTracking dumber <br /> WASTE MANIFEST ICAL000371993 80092.46804 � 008572474 F L E { <br /> 5,Generators Name and M d ng Address Generator's S:teAddress(mf different than mailing address) <br /> Dollar General #13357 Dollar General#13357 <br /> 8092531654 1901 WEST MAIN STREET 1201 WEST MAIN STREET <br /> Generator's Phone: RIPON, CA 95365--3027 RIPON, CA 95356-3027 <br /> 6.rmnsporter 1 Company Name U.S.EPA ID Number <br /> Sterievcle Si3ecialty Waste Solutions Inc IMNS000110924 <br /> y <br /> woo w Y Cunpa Name U S,EPA ID Number <br /> ", r i2(?i� tri-e.�t. ��`� � P'� 4,P f C#�� 17 <br /> B.OesignnledFadlilyNameaj�iySlte ""'General Environmental I4�t, LLC US.EPA IDNumber <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facipl a Phona>} 1ggth I ranqAa aa41 g,7 <br /> ga, 9b.U.S.DOT Description(including ProperShlpplag Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wtivol <br /> X ON31391 Waste Oxidizing liquid, n.o. s, 1 DF 00100 P 141 D001 <br /> (Hydrogen peroxide), 5. 11 PG 11, ERG#140 <br /> U=X 31419931 Waste Flammable 1 iquids, n.o.sK i DM 00002 P 331 x001 <br /> (Alcohol), 31 PG II, ERG#128 <br /> X 13N30777 Waste Environmentally hazardous 1 CF 00002 p IBI 009 <br /> substances, solid, n.o.s. (Mercury, Broken <br /> =luorescent Light Tubes), 9, PG III, ERG#171 <br /> X 16JN19501 Waste Aerosols, flammable 2.1, ERS#126 i1 CF 00012 P 331 6011 <br /> 4.Special HandlinginstrndipnsandAddmtionalInformation 1. 110525(Oxidizers, Liquid - Loosepack) 2. 110518(Flammable <br /> Liquids - Loosepack) 3,110544(Merciury Containing Waste (Broken Fluorescent tamp)) 4. <br /> 110541(Aerosols) <br /> 15. GF.NERATOR'StUFFEROR'S CERTiFICAT(ON:I hereby declare(hat[be contents of this consignment are fullyand accuraiely described above by the proper shipping name,and are rdassified,packaged, <br /> marked and labeledlplacarded,and am in all respects in proper condition fortransport a=rding to applicable international and national governmental regulations.If export shipmentand I am the Primary <br /> Exporter,I certify that The contents of this consignment conform to the terms of the attached EPAAckrwwiedgment of Consent. <br /> certify that the waste minlmlzaeon statement Identified In 40 CFR 262.27(a)(f i am a large quantity generator)or(b)(if l am a small quantity generator)is true f <br /> rawso yp me igna re MINldl Day rear <br /> 3'" 10 Ili X016 <br /> =S.Intomational Shipments <br /> ❑Import to U,S. EJ Export from U. Port of entry/exit. <br /> Transpodersi.nature(for exports onlvt: Data leaving US.: <br /> 17.TransportorAdcnowledgmentofRecalptofMaterials _ <br /> IraWortiss t Printedlfyped Nerniii gna re Month ay Year <br /> Phil Marc i e l x i \�J�,C�t,� lie <br /> I it 101F2 <br /> 1Yansp r2 dName Signature 11 Month f]ay Year <br /> /011 /& <br /> 16.oiscropan <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑partial Rejection ❑Full Rejection <br /> I <br /> Manifest Reference Number, <br /> 18b.Alternate Facility(or Generator) US EPA ID Number <br /> 1 <br /> U <br /> Fa_dlity's Phone: <br /> t 5[gnatuceofAttemateFactBty{arGeneratos) Month Day Year <br /> 19.Hazardous waste Report Management Method Codes 0 a,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> I2 3 �4 �r t <br /> 20.6081 FKYOwner orOperator CeibEcationofreceipt ofhazardous materials covered byIke manifestexce tasnoted Ileml8a � <br /> nted Name S re I Month lay ear <br /> fQ EPA Fotm 8700. 2( ev. 05) Previous editions are obsolete. a -DESIGNATED FACILITY ATION STATE(IF REQUIRED) <br />