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PI <br />r <br />'ase print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 <br />UNIFORM HAZARDOUS'- Generator ID Number 2 Page 1 of 3 Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST I CAL000374240 11 18775772669 I 010868403 F L E <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Dollar General #13585 Dollar General#13585 <br />209684986E 2150 W ALPINE AVE 2150 W ALPINE AVE <br />I Generator's Phone: STOCKTON CA 95204-2853 STOCKTON CA 95204-2853 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Stericycle Specialty Waste Solutions Inc MNSOOOII0924 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />r c2h4l- //-/ ')4-1-104A41 <br />signaled Facility Name and Site Address 219t Century EMN, LLC U.S. EPA ID Number <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />W_ <br />0 <br />W <br />z <br />w <br />Facility's Phone: 7755752760 I NV <br />8 <br />9a. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Nacre, Hazard Class, ID Number, <br />and Packing Group (if any)) <br />10. Containers <br />11 Total <br />Quantity <br />12. Unit <br />Wt.Nol, <br />13. Waste Codes <br />No. <br />Type <br />X <br />1UN1993, Waste Flammable liquids, n.o.s. <br />(Alcohol), 3, PG II, ERG#128 <br />1 <br />CF <br />00010 <br />P <br />331 <br />D00i, <br />1 <br />I <br />X <br />2UN1950, Waste Aerosols, flammable 2.1, ERG#126 <br />1 <br />CF <br />00006 <br />P <br />331 <br />D001 <br />3- <br />4 <br />114.tipeciainanaunginstructions anoAaamonaimronnaaon 1. 110518(Flammable Liquids - Loosepack) 2. 110541(Aerosols) <br />15 GENERATOR'S10FFEROWS 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 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 EPAAcknowledgment 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 gvier r) is true. <br />Printed/Typed Name e n _ onthay Year <br />041 041201 <br />1 ational Shipments <br />❑ Import to U.S. ❑Export from U.S. Port of entry/exit: . <br />Transporter signature (for exports only). Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />Trardrporler 1 Printed/Typed Name ignature Month ay Year <br />Johnny Haroer I i 04� 041 <br />Transporter rvtedriyped� /� ISignature (\� IMonth� Day <br />Year <br />1/d <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity <br />18b. Alternate Facility (or Generator) <br />J_ <br />V <br />LL Facilitv's Phone: <br />C3 18c. Signature of Altemate Facility (or Generator) <br />Q <br />Z <br />CD 19. Hazardous Vaste Report Management Method Codes (i.e. <br />LLI -Hl�(1 I2 t <br />❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />hazardous waste treatment, disposal, and recycling systems) <br />20. Designated Facility,Pwner or Operator: Certificatioon of receipt of hazardousmaterials covered by the manifest ex as noted in Item 18a <br />Printedrryped Nameluoyma n <br />ILI_ /s - I S gnatura A <br />orm 8700-22 (Rev. 3-05) Previous editions are obsolete. DD SIGNATEQ FANLEU T9 DESTINATION STATE (IF I <br />8700-2212v3 CAL20072032 541053281 041080647 M PD040418 SD040418 <br />