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S �1�111�11�1�1 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS J1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST rM Ifisul qq JR775772figq 010790218 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Dollar General #13357 Dollar General#13357 20192531664 1201 WEST MAIN STREET 1291 WEST MAIN STREET Generators Phone: RIPON. CR 5366-3027 I R P _ f A 7 6 Transporter 1 Company Name U.S EPA ID Number v ct a Rn 1 ut i nn nr• I A 7 Transporter Company Name n r U.S EPA ID Number ,Irak t� r!� � �-. I A,4"J 8,Designated Facility Name and Site Address U.S.EPA ID Number MOFacili f's ga. 91b.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 WI.Nol. o X bN1950, Waste Aerosols, flammable 2. 1, ER6#126 1 CF 00020 P 331 D0011 Lu X bN1993, Waste Flammable liquids, n.o.s. 1 CF 00811 P 331 D001 (Alcohol), 3, PG I1, ER6#128 X bV3139, Waste Oxidizing liquid, n.o.s. 1 DF 00091 P 141 D001 (Hydrogen peroxide), 5. 1, PG II, ERG#140 6n RCRA hazardous waste, liquid (Consumer 2 DF 00240 P 331 Products), 14,Special Handling Instructions and Additional Information 1. 110541(Aerosols) 2. 110518(Flassable Liquids - Loosepack) 3. 110525(Oxidizers, Liquid - Loosepack) 4. 110524(Non-RCRA Liquid Waste (CA Only) - 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 international 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 EPA Acknowledgment 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. Ganem yp Name Signature Month Day Year de a a 690 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _ Z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day I Year �_.._—: Z _�_�2 me � Signature rrL . 1707 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantityyp ❑Type 1:1 Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Z F, 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU �1 ILt I I2. U )(-(f I3 U 1 ,g� I4 i-I.t q I 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a rlWyVed Name Signature Month Day Year M n V1P 11>0 -3" t, r Ina M I " . -- IvciIrQ6l 1`) EPA Form 8700-22(Rev. -05) Previous itions are obsolete. D-felhNATED FACILITY TO DESTINATION STATE(IF REQUIREb)