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Please print or type. (Form designed for use on elite (12-oitchl tvoewriter.l 111111101111111 Fnrm AnnrnvM OkAR Nn )nrn.nn,:tQ trA norm oivu-« (nev. coo) rrevlous eumons are oosoiete. U DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) ..8700722i,42u3-CAL20107e032_ S4t053?81_.2_„D40192135Z M - PD12IM17 9DO82917 ... . UNIFORM HAZARDOUS 1. Generator ID Number I 2. Page 1 of 12 3. Emergency Response Phone 18775772669 4. Manifest Traumber I 016"985538 WASTE MANIFEST CAL000374240 F L E 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Dollar General #13585 Dollar General#13585 2096849866 2150 W ALPINE AVE 2150 W ALPINE AVE Generators Phone STOCKTON, CA 952204-2853 STOCKTON, CA . 95204-2853 6. Transporter 1 Company Name U.S. EPA ID Number Stericycle Specialty Waste Solutions Inc I MNS0001109^24 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number ^s �� oy Facili Plwne: NY l ga, HM 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any)) 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type Quantity Wt.Nol. X 1UN1950, Waste Aerosols, flammable 2.1, ERG#126 1 BA 00001 P 331 DOM 0 gn. w X 2IJN1993, Waste Flammable liquids, n.o.s. 1 CF 00003 P 331 D001 (Alcohol), 3, PG II, ERG#128 X 3UN3266, Waste Corrosive Liquid, Basic, i CF 00011 P 122 DOM Inorganic, N.O.S. (Sodium Hydroxide, Potassium Hydroxide), 8, PG II, ERG#154 Waste Environmentally hazardous 1 CF a0001 P. 181 D0a9 substances,- solid, n. o. s. (Mercury, Broken Fluorescent Light Tubes), 9, PG III, ERG#171 14. Special Handling Instructions and Additional Information 1. PKG-DF :110541( Aero s o 1 s ) 2. 110518 (F 1 am mab 1 e Liquids - Loosepack) 3.110515(Basic Liquids, Inorganic - Loosepack) 4.110544(Mercury Containing Waste (Broken Fluorescent Lamp)) 15. GENERATOR'S/OFFEROR'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 Irderna�national mental regulations. If export shipment and I am the Primary Exportor. that the this to the terms the EPAAcknowredgntett( ' ` cw* contents of wnsignrnent mnfonn of attached nt 1 cartiiy itot the waste m nimization statement Identified In 40 CFR 262.27(a) (if I am a large quantity gerordbtr16r (b) (if i gepnmp, �rup:'. Generator's/ roor Printed/Typed Name / gnatu Month Day Year JJA J 2 16. InterMional Shipments ❑ Import to U.S. po ❑Export from U.S. Z�D.teof entry/exit: Transporter signature (for exports oniv): IeavinQ U.S Lu 17. Transporter Acknowledgment of Receipt of Materials � Transporter 1 Printed/Typed Name 'gnature Montn ay Year a0_..,.I:sidro Mart4nez..-:.. I , ta8�...29�21A1 z Tran 2 Pr in yped Name Signatu Monin Day Year 18. Discrepancy 18a Discrepancy Indication Space ❑ Quant' ty El Type El Residue ❑Partial Rejection ❑Full Rejecfan Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ V LL Facilitv's Phone: Lu 18c. Signature of Altemate Facility (or Generator) Month Day Year Z H 19. Hazardous Walte Management Method (i.e., codes for hazardous waste waste treatment, disposal, and recycling systems) 1 (Report l (Codes 2. `f'! � — 1 i I3 4 ' � \ 1'` I 1 14 f I l� " l 1 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Iter�i8a Printed/Typed Namer U'LIOL-b igna ure Mot Day Year I rL, --� I (/J Z/0I I i(� I f trA norm oivu-« (nev. coo) rrevlous eumons are oosoiete. U DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) ..8700722i,42u3-CAL20107e032_ S4t053?81_.2_„D40192135Z M - PD12IM17 9DO82917 ... .