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Please print or type.(Form designed for use on elite 12-pitch)typewriter.) 111111111111111Form 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 1 CAL000374.268 11 � 8775772669 1008553849 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dol.lar4 General #13593 Dollar General#1359,?, <br /> 209$00$r22 44232 'E MAIN> 4232 ,E MAIN <br /> Generam PFgnrs' STOCKTON , CA 95215-6722 I STOCKTON. CA 95215-6722 <br /> V. rarrsporter 1 Company Name U.S.EPA 10 Number <br /> Stericycie SPecialtY Waste Solutions Inc I MNS000110924 <br /> 1.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.1 Desiguled Facility Name and Site Address General Environmental Mgt, LLC US.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Facili( s Phone:91635 10980 I A4 ? <br /> 9a_ 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 Wt.Nd. 13.Waste Codes <br /> ,X 'UN1950,. Waste Aerosols, flammable 2..1, ERG#126 1 BA: 00003 P 331 D001 <br /> 0 <br /> w <br /> w +ion 'RCRA hazardous waste, liquid (Consumer 2 CF 00062 <br /> 0 Products), P 331 <br /> 3NonI RCRA ::hazardous„waste, solid (Consumer 1 CF 0001:3, P 3-31: 1 <br /> Produgts), <br /> 4, <br /> 14.Special Handling Instructions and Additional lnformation 1,PKG—DF:11@541(Aeroso-ls) 2.,110524(Non—RCRA Liquid Waste .(CA <br /> Orly) .- LGose.Packi) 3.1,10529(Non—RCRA Sol <br /> id Waste (CA Only) — Loosepack) <br /> 15, GENERATOR'SIDFFEROR'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, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.9 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)am a small quantity generator)is true. <br /> otod� [ yped Name } <br /> Month Day YM <br /> �,:_ .. IM7I Pi [Poll <br /> J 16.Intemalidnal Shipments <br /> �— IX <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> T r signature(for exports only): Date leaving U.S.: <br /> LLI <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name <br /> Signature Month Day ear <br /> O I �� <br /> Qa Isidr^a.Martinez I: I_,21LPA711I <br /> Transporter 2 Ptintedlfyped Name ture Nbnth ay Year <br /> 18 Discrepancy <br /> I i I I <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> J <br /> L> <br /> Q II Fa” a Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> WZI I 1 <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 k\ 2 \ 3 4. <br /> 20,Designaead Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manrfest ex In Item 180 <br /> nfedfiyped eyln� <br /> 4. th �Da]� Year <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. I I l N-7 <br /> DESIGN ELr FACILITY STINATION STATE(IF REQUIRED) <br /> 870,0 22___12v3 CAL20072032 541053289 n4thA49Ir,44 M t nI07P 1 17 Qnot7a1I 17 <br />