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Please print or type.(Form designed for use on elite(12-pitch) writer. <br /> �� ) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000374268 11 18775772669 011434269 F L E <br /> 5.Generators Name and Mailing Address Generalar's Site Address(if different than mailing address) <br /> Dollar General #13593 Dollar General#13593 <br /> 2098008822 4232 E MAIN 423E E MAIN <br /> Generators Phone: STOCKTON. CA 95215-6722 STOCKTON. CA 95215-67222 <br /> 8.Transporter t Companyi,ame U.S.EPA ID Number <br /> Stericvcle Snecialty Waste Solutions Inc MNSOOOIlOC124 <br /> 7.Tranaporler 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Daslgnated Faciiiiy Name and Site Address 21st Century EMN, LLC I U.S.EPA ID Number <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 <br /> Facilil s Phone: 7753752760 INU <br /> ga 1 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity I Wt.Nol. 13.Waste Codes <br /> X 1UN1950, Waste Aerosols, flammable 2. 1, ERG#126 1 BA 00011 P 331 D001 <br /> 0 <br /> w <br /> Z X 2UN1791, Waste Hypochlorite Solutions 8, PG 1 DF 00077 P 122 D002 <br /> III, _ ERG#154 <br /> X:. 31M130771 Waste Environmentally hazardous 1 CF 00001 P . 181 D009 <br /> substances, solid, n. o.s. (Mercury, Broken <br /> a.Fluorescent -Ligh:t Tubes):, -:,.9, P6.114 ERG#171.. <br /> 14.Special Handling Instructions and Additional Information 1.PKG-DF:110541(Aerosols).. , 2. 110517(Bleach, Liquid) 3. <br /> 110544(Mercury Ca:nta ni-ng Waste (Broken Fluorescent Lamp)) <br /> 15. GENERATOR'S/OFFERORS 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 EPA Acknowledgment of Consent. <br /> I certify that the wa54 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. <br /> nrNato B n me Sunature Month Uay year <br /> � 18.1 Donal <br /> AAI IRA 1 a <br /> F- <br /> 11 Import to U.S. ❑Export from U.9�� Port of entry/exit: <br /> Tran rg3r lure for ex only): �� Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdnb&7yped NameSignature <br /> Month Day ear <br /> Isidro Martinez: 08� 08� 201 <br /> zTransporter 2 Printed/Typed Name Signature Month Day Yeer <br /> ~ I I <br /> 18.Discrepancy I <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ ❑ Refection El Full Rejection <br /> Type Residue Partial Re' tion <br /> Manifest Reference Number: <br /> IZ 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> V <br /> LL Facili s Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !R- <br /> Z <br /> w 19 Hazardous Waste Report Management Method Codes(i.e.,codes <br /> for hazardous waste treatment,disposal,and recycling systems) <br /> 1— �A�q t 12 ll A I3 OW 14, <br /> 20.Designated Facility Owner or Operator.Certification of receipt 01 hazardous materials covered by the manifest e t as noted In Item 18a <br /> I MOgt I Day 1—Year <br /> l\ <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED ACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 8700-22_12v3 CAL20072032 S41053289 041144755 M PD080818 SD080818 <br />