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Please print or type.(Form designed for use on elite(12 pitch)typev7rrler.) G,q Ci 4:: L FormApproved.QMS No.2050-0039 UNIFORM HAZARDOUS 1-Generalef ID Number 2,Page 1 of 3 Emergency Response Rhone 4.Manifest Tmcgin Number WASTE MANIFEST CAL©0039s166 2 ($77) 577—'?6h 00 01 5 $ DAT 5.Generators Name and Mailing Address Generator's Site Address(if diflerent than maiang address) HG LOTS STORES 116 LOTS SIM 300 PPILLIP Rig Al IN: DERR FEPP.RU 2729 COUATRY CLUY DRIVE GeneratorsPhono: COLLMUS Ol 0229 (6Id127B-27D8 SIOUTOR ;"R 35201 U.Transporter 1 Company Name U.S.EPA ID Number STE RICY-LE SPECIALTY WnSTE SOLA T 10145 INC f11dSQflGlla�s � 7.Transpo er 2 Company Name U.S.EPA 10 Number 8.Designated Facility Name and Site Adddss IL U.S.EPA ID Number 71ST CUTURY ENVIROMERTRL rM-RGEKERT OF NEVPD;#, LLC 2Q4S Hemiands Drive East FarilitysPhone: FERNLEY, NY 8908 (715) 575-2766 NVD98E}895 36 ga. gb.UOT Description(incdudina proper Shipping Name,Hazard Gass,10 Number, HM and Packing Group{if any)] 10.Containers 11.Total 12.Uri1 13.Waste Codes No. Type Quantity WlJ1,ld. 1 UNI950 URSTE R[ROSOLS 2.1 800491=I489J T 3I J)0RI 2Lai . n„r y� - � 1 J25E .,,1- 1,WN11V,11TL 1 L L, 11RHP, 1 n, _ l .. M1 -. s . ; • a a- r « 4- W1993 URSIL FLPtZtAKE LIQUIDS, N.0.5_ (8ERO5ENE, BIESR 1 3 FGII 311 X R0000I=III01 44 I �f 14.Special Handling Instructions and Ad&ficnal Information (IJ REstlSOLS-D3 - ERG(126) AEROSOLS Hill aR 'UQfD 65 Fftii3t) ftefMAID e6RRfttVf - - , MIC CORROST rt MQU {>;P ➢LFLRFiLIO-D3 - ERGi1291 FLP ,lRILE LI 15, GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,a are classified,packaged, marked and labeledlptacarded,and are in a8 respects in pmper cond tion for transport according la applicable international and national governmental regulations.If export ship nl and I am the primary Exporter,I certify that the contents of this consignment conform to the lerms of the attached EPA Acknowledgment of Consent. f certify that the waste minimization slalemenl identified in 40 CFR 262.27(a)(if I am a large quantity genera(m)or(b)(f l am a smalligquuaaan/tity generator)is true. GeneralorslOffemrs PrintedRyped Name Signature ,�`G L MDay Year l f /7j/L t10 16.In emotional Shipments F- Import to U.S. L1Export from U.S. Pad of entrylexiL Transporter signature(for exports only): Date reaving U.S.: w 17.Transporter Acknardedgment of Receipt of Materials OTransport 1 Printedliyped Name Signature Month Day Year W r 1� Q Trans rter 2 Print Name Signature Mo ay Year 17_ 18.Discrepancy 18a,Discrepancy Indicaton Space ❑ Quantityype ❑T Residue ❑Partial Rejection ❑Dud Rejection Manifest Reference Number: 18b.Allemats Farxlify{or Generator} U.S.EPA ID Numbar U Fatality's Phone: LO 18c.Signature otWlemaie Faulily{or Gene2lor} Month Day Year H z CD ft,.Hazardous Waste Report Alanagement Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. r ` 2. 3. 4. 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the nanifesl except as nded in Item 18a PrintediTyped Nam Signature Month Day Year I n 1 EPA Form 870622(Rev.3-05) Previous editions are otisolele. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)