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a � III�IIiI002 u011324PiSIc�Aiii }_- 33sa3s1-ao1 <br /> 'lease print or type.(Form designed for use on.eRe(I2 pitch}:typewriter} A Form APprovwd €7M13 No.2050-0039 <br /> UNIFORM HAZARDOUS' 1:Generator 10 Number2.Pam 1 of .3.Erltiergaticy Response Phone 4-Manifeslt Tra"g.NuwAw " <br /> W74STEMANIFEST CAL000391074 {87 577-2655 002002324-PSC . <br /> 5.Generalo s Name and Mailing Address Generator`s Site Atfdress(if ifterentihan maAng address). <br /> SIG.LOTS STORES <br /> BIG LOTS 1#41Q6. <br /> 3WPHILLIP Rb,ATTN:DENA FERARU - 380 S CHEROKEE LAVE <br /> COLUMBUS,OH 43225(614)278-2708 LODI,CA 95240 2093586559 . <br /> Generator's Phew:. <br /> 6.TraoWder I Company Name U.S.EPA 1D Number <br /> STERICYCLE SPECIALTY WASTE SOLtl f14S-INC MNSODO#10924_ <br /> 7.Transpofter2_Company NameU.S.EPAID Number <br /> AV <br /> 8.Designated Faclity Name and Site Address US.-EPA 10 Number ' <br /> 21st Century Envirenfrlental Managener►t of Nevada'LLC NVD980896M <br /> 2095 Newlands Dr.East, <br /> Fernley NV-89408 (775).575-2760,, _ <br /> FaciliVs Phone: <br /> 9a: -9b.U.S.DOT DesCIM00([chiding Proper Stripping Na*,Hazard Gass,IU Number,- 1U.Gontafi %Total - 12 Unit <br /> 73. .Waste Codes <br /> HM and Packing.Group(if anY)I No. _Type Qum*-: NM.A?ot <br /> I, UN1W WASTE AEROSOLS 2.1 <br /> � - - 331. ,� Da01 _ <br /> - - - - _ - -i- -' TJF 8 .113 - , - <br /> } <br /> 2 UN2M(r WASTE TOXIC.LIQUIDS;ORGANIC,N_O.S-(2,4-D)5.1 PGIILU 1 X016 i <br /> X 1 QF 32. P — <br /> 3. UW32.66WASTE 0011ROSIVE 1-101.116,SMIC,INORGAtW,1_�LO-S-(SOd UM IiYDROXIDE, :141 I Df162 <br /> POTASSIUM HYDRi0ADE)8 PGII - - - - - <br /> X .. - - 1 DF.. g p <br /> 4. UN1791 WASTE HYPOCHLORITE SOLUTIONS a PGA <br /> 1 <br /> - <br /> ' 14.Spacial Handln9 ttrsltuctioals and Additional Information - <br /> (1)RLAERO$OLS-04-ER0(125)SLAUWSOLS-04-AEROSOLS(2)81-TOXIC-03-ERG(153}OLTOXIC-03-TOXIC LIOUI€IS LOOSEPACK(3)BLfiORR$ASIG04•ERG(1154)BLCORHBASIC-04• , <br /> BASIC CORROSIVE LIQUIDS(4)WMGTOLEACH-04-ERG(154)BLEACH <br /> i5; M.NERATOR'VOFFEROR'S CERTIFICATION:I hereby decSare That I*cornu of this consignment are fully and accurately descnbed-above by the proper shipping name•and are cbssfied,packaged, <br /> marked and tabeled,�slaearded,and are in a0 respects in proper Condition for transport according to appticab#e idemwipnal acrd national governmental regulations-If eVart shomem end I am the Primary <br /> Ekporter,i cerlify that to contents of this consignment conform to.the terms 0 the attaetled EPA Atknowledgmoni of Gorrsent. <br /> I onrfify that lire waste rninimizaEibrrsiaternent ideni% in 40 CFR 26227(a)(d I am a terga gene, tb)J41 atn I quantity generator)is true., <br /> Generatorsf sy me gn to aY ear <br /> �► �V Cd 10 16 1.8 <br /> -A 16.Internation i Shipmenifs <br /> ❑Import to U-S lrom U.S: Past zit <br /> Trans er si ature for ex and Ie waving(JS,: <br /> LU <br /> A= 17.7ransportarAcknowiedpwil.atReceipt ofMailed* <br /> 12 Transporter 1 Pdntedffyped Name notate 4 Year <br /> n. And Winkler 1 10 16. 1 18 <br /> Q Trarasporter 2 PWtedf fed Name h rgnature Y. Year <br /> 19a.Discmpancy Indication Spaoe Eloum' lity ❑Type FIResidue. ❑Partial Rejection DUO ulf Rejactia€i ; <br /> MaWkst Retrence Number: <br /> 18b.Aftemale FacA1y for Gent) U.S.EPA 11)h)umber <br /> Fapifi s Phone: _- <br />- isc.Soatureotmematefacility(or.Genwaitor) Rkonih f3ay Year <br /> LUr <br /> 19.Hazardws Waste ftepod Management IAethad Codes(i.e-.codes for hazardous treatment,disposal,and recycling syslems) <br /> I. H141 2. H141 a. _ a } 11070 <br /> 20-besgnated facility Domer or operator.Cedift ation of receipt of hazardous materials covered by the nsanifost exce noted in Item I Sa <br /> Pdniedffyped_ 5igr alum Month Dav _Y1w. <br /> EPA Form 8704-22(Rev.3.45) FTevious editions are absolete, <br />