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�II� II <br /> Please int or e. Form designed for use on elite(12-pitch)typewriter.) ERT 111 .1111131111111111 IForm Approved.OMB No.205MO39 <br /> Pn type.� 9 ( � )tYP ) pp <br /> UNIFORM HAZAROOt1S I1.GeneratorlD Number 2.Page 1 of 13.Emergency Response!'hone �4.Manifest O O 15 7 022 FLE <br /> WASTE MANIFEST CAL�1410374268 8009246804 <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Dollar General#13593 <br /> 2098008822 4232 E MAIN <br /> Generators Phone: STOCKTON, CA 95215-6722 <br /> 6.Transporter 1 Gompany Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc I MNSOOOI10924 <br /> 7.Transporter 2 Comparry Nems U.S.EPA to Number <br /> I� tic �e :{tn-Fey �g91)a[OZO 1''1 <br /> 8.Designated Facility Name d Site Address r , 4LL U.S.EPA ID Number <br /> 11855 White Rock Road <br /> Rancho Cordova, CA 95742 <br /> Fadlily's Phone: 9163510980 I CAD980884183 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers It.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity WINd. <br /> rr <br /> 1. UN19VO, Waste Herosots, tiammatl a 2. 1, 1 0 013 P 33 D00 <br /> a <br /> Z x 2. N1! 1, waste Hypochlorite tiolutions 8, 1 CF 00004 P 12. <br /> III, ERG#154 <br /> 3- Non RCRA hazardous waste, liquid (Consumer I CF 00039 P 3 <br /> Products), <br /> 4. universal Waste Fluorescent Lamps 1 CF 00002 P <br /> 14.Special Handling Instructions and Additional Information 1. 110541(Aerosols) 2. 110517($1 a ach, Liquid) 3. 11 @524(Non--RCRA <br /> Liquid Waste (CA Only) - Loosepack) 4. 110521(Fluorescent Lamps UW - Misc. Shapes) <br /> 15. GENERATORMIOFFERORM CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately deskxkbed above by the proper stripping name,and we classified,packaged, <br /> marked and labelledlptacarded,and are in at respects in proper condition for transport according b applicable international and national governmental regulations.It export shipment and I am the Primary <br /> Exporlar,I certify that the contents of this=signment conform to the terns of the allached EPAAckrvMedgnwt of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(id I am a s=1 quantity generator)is W e. <br /> fwae <br /> ws PrimedoTyped Name nor. e � Month Day Year <br /> Klkelllx(�i <br /> r�&F <br /> pmems <br /> v <br /> H L J Import to U.S. ❑Export from U.S. Port of enbylexit: _ <br /> ? Transporter signature(for exports only): Date teainu U.S.: <br /> I= 17.Transporter Acknok�neni of Receipt of Materials , <br /> Transporter 1 Printedayped Name gnature Month 03y Year <br /> a <br /> Johnny Harper 1q 0q 2016 <br /> N <br /> Q T`�°�2 ypad Name gnature a ! Month Day Year <br /> L I I !dl /I 1 /k0 <br /> 18,DiscrelAncy <br /> 18a.Discrepancy Indication Space ❑Quanti T Residue <br /> ty ❑Type, ❑ Partial Rejection ❑Full Rejection <br /> i <br /> Manifest Reference Number. <br /> 18b.Atemate FaciTty(or Generator) U.S.EPA ID Number <br /> v <br /> LL FaaTkh(s Phone: <br /> L t 180.Signature of Allemate Facility(or Generator) Month {{ Day Year <br /> Z I 1 1 <br /> y19.Hazardous Waste Report Management Method Codes(i.e..,,codes for hazardous waste treatment,disposal,and recycling systems) I � l 1 L' <br /> 0 1. 2. rte!L4 1 1'* `i�t'" I L 1 14 �F_4 f 1 1 <br /> 20.DepgAo Fac>7ity O6&or Operator.Certification of recei kf hazardous materials covered by the manifest except as noted in jKm 18a rI <br /> P*gef <br /> Name t e 5lgnature ! Month Day Year <br /> EPA Form 870122(Rev.3-05) Previous editions are ob DCSIGNATED FACILITY TO TINATION STATE(IF REQUI ED) <br /> Lam' <br />