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Ptease print or type. (Form desiqned for use on elite (12 -pitch) typewriter.) ER 189111�1111Il1110 Form Annroved. OMB No. 2050-0039 EPA Form g7t)0-2 (Rey. 3 %) Previous editions are odsuleeT— � A)ESIGNATEO FACILITY feSTINATION STATE SIF RE6UTAEDj hi Rnl09,1416 SDIO0416 UNIFORM HAZARDOUS 1. Generator ID Number I 2 Page 1 of 3. Emergency Response Phone 4. Manliest Tracking Humber 1 WASTE MANIFEST CAL000374240 2 8009246804 F L E 009157021 5. Gens Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General#13585 2096849866 2150 W ALPINE AVE G s Phone: STOCKTCN, CA 95204-2853 6. Trartsporter 1 Company Name U.S. EPA ID Number Stericycle Specialty Waste Solutions Inc I MNS000110924 7. Trate 2 Company Name U.S. EPA ID Number afc 05wir 1 sf Gl,� t i' I G/off/7 U. taelFacilityHame ndSiteAddress General Environment l Mgt, LLC U.S. EPA ID Number 11855 White Rock Road Rancho Cordova, CA 95742 Faclkes Phone: 3 9A I cenq 183 ga. 9b. U.S. DOT Description Canclu ft Proper Shipping Name, Hazard Class, ID Numb" 1 10. Conga ners ii. TOW 12. Unit 13. Waste Codes No. Type HM i and Packing Group (if any)) Quantity Wt.Nol. c X 1. UN1950, Waste Aerosols, flammable 2. 1, ER3#12E 1 CF 00011 P 33. D001 LU X 2' UN1993, Waste Flammable liquids, n. o. s. 1 CF 00008 P ' 33 D001 (Alcohol), 3, PG II, ERG#128 X 3, UN1325, Waste Flammable solids, organic, n. o. 1 CF 00002 P 35 D00 s. (Sulfur), 4.1, PG II, ERG#133 -1q•Consumer Electronics for Recycling (General E-, 1 CF 00009 P 1$ Waste), - 14. Speciall Handling Instructions and AdditionallnformoW 1. 110541 (Aerosols) 2. 110518(Flammable Liquids - Loosepack) 3. 110519(Flammable Solid - Loosepack) 4.110548(Consumer Electronics for Recycling) 15. GENERATOR'51OFFERDR'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 labeledlplacarded, and are in an respects in proper cmdltfon 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 attechod EPAAcknowtedgment of Co I certify that the waste minimization statement Identified in 40 CFR 26227(a) (it I am a large quantity gs--41or (b) -An WWI quan-4 generator) is we. 1"7'Y aria nth ay Year /nn�tediT�jedf �am�e M V1�f ►W I 1� 0 201 F- . TU-Stennational Shipments❑ F_ frau U.S. ❑ Import a, U.5 entryler-t: T signature (for exports only): Date leavinq U.S.: aTransporter 17. Tmmpo WAdcmwledgmentol Rec* of MateriWs 1 PrintMTypcz Name Signature Month say Year nhnnv HarDer I 1 14 a 20if 2 P - Name Signature L1 on Uay Year i' laer' I V I �o P18Di. capa 1Be. OLumpartcy indication Space C] quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Affernate, Facility (or Generator) U.S. EPA ID Number J U I Fadfrty s Phone: 18c. -Signature of Alternate Facdity (or Generator) V..onth Day Year ZCD 1 I I 19. Hazardous Waste Report Management Melhod Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) 1Rjq I ` --� i3 1 �4 4+1141 Z0. FaaLty Onrier a t?peratar. Certifiratiori of receipt of hazardous matedah co++eted by Ute marrifest except as ndled n t `� - Ltrith Day Year 1 EPA Form g7t)0-2 (Rey. 3 %) Previous editions are odsuleeT— � A)ESIGNATEO FACILITY feSTINATION STATE SIF RE6UTAEDj hi Rnl09,1416 SDIO0416