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337Rxe. <br /> Pleas (Farm designed for 00196EI846PSC 3309485-001 <br /> use 4n elite-[12-pitlir)tyPewrRer.f <br /> UNIFORM ffAZARD4US t."'u-tor ID Number Fomt Reproved_OMB.No.2050-0039 <br /> 2-Page.}of 3.Ernergencp Response Phone 4.Manifest Tracking Number WASTE MANIFEST CAL000391073 1 ($77)577-2GG9 �V1 wed- PSC <br /> 5. eneratUr's ST and AAailing Address Generator's Site, (if d fferent than mawrg address} <br /> BIG LATS STORES <br /> 300 PHILLIP RD,ATTN;DEIdA FERARU BIG LOTS#4457 <br /> COLUMBUS,ON 43228(614)278-4614 <br /> 2881 N.TRACY BLVD, <br /> Genemlor'sPhone TRACY,CA$5376 2.)98306312 <br /> &. ransporter 1 mpany aline <br /> STERICYCLE SPECIALTY WASTE SOLUTIONS INC U.S.EPA!D Number <br /> 7.Trans orter2Com yhlame MNS000110924 - <br /> goIS,FPA ID Number <br /> Designated FaCjlity Name and Site Address <br /> 21st-Cent,ry Environmental Managefnent of Nevada LLC US.EPA If3 fJum6cv <br /> 2095 Newlands Dr.East, NVO98ONS338 <br /> Femley NV 89408 (775)575-2760 <br /> Facia ify's Phone: <br /> ga. $b.U S.DOT Description(including Prmper Shipping Name,Hazard Class,ID Number. T10-QDntaiwrsHOA and Packing Group(ifany)) 11.Total r3Z1 <br /> Quahbly 1. U[1791WASTEHYPOCHLOAiTESOLUTIONS9PGIIx 23 2. UN2Bi0 WASTE TDXIC,LIDI,pp$,ORGANIC,N.O.S.(2,4-0) <br /> 6.1 PGIIDF 53 3. <br /> 4 <br /> 14-Special Handling In5n3tCf oras arld Additional information <br /> (1)WMGTBLEACH-04-EAG(154)9LEACH{2)BLTOXIC-M-ERG(153)6LT0XJC-03-.TOXIC L!OWDS LOOSEPAGK <br /> 15,, GEhfERATOR'SipFfERORS CERT3F1CATfOC4: thereby declare}hal the Contents of Otis Consignment ate fully and amurabely described above by the proper shipping name,and are dassified,packaged. <br /> marked and Ea6efedrp acarded,and are in ail respects in proper condition for transport according by appl cable intamat onal and nal o rat ernmrntal <br /> Expoger,!cellify IML the contents of this consignment Conform 10 the ferias ce the alt ache d EPA AcknowWpent of Consent, regulations.ff exMrl shipment and I am the Prmtary <br /> I certify final Ir+e waste minimization sOatement idenlil-sed m 4U CFR 262.27{al(rf I am a targe qu3n6ty generatnrj or(b}(i(I am a small quanf'sfy generaforJ is t . <br /> MAC <br /> s rated, yped <br /> Ur WE Y. . ear <br /> W-4I 1&.fniernalionaf Shipments 9. 17 18 <br /> y- ❑I to U-S. LjEx rt arum U.S. Port of enlryieft <br />� Tran er si nature for ex rts ON - -- _ <br /> 1 17.Transporter A.�rnowledgrnpff of Re eip[of 0hakxiak luavin U, <br /> f-- 14anspor!er 1 Nn t FIT_yped Name agna ure <br /> 0- Darryl Johnson <br /> X Trans r PrintedlTyied N r 9 17 18 <br /> Q ur <br /> f fiAonih ay ear <br /> 18.Discrepancy � (✓ . f <br /> 18a,DisCrepanr.YlrtdicationSpaca t)uantity �rYpo <br /> Residue ❑Partial Rejection ❑ u0 Rejection <br /> Imo._ 18b.Afernale.Fac-ity(or Generator} !Jlanifesi F<eference Number . . <br /> H-5.EPA I D Number <br /> u <br /> d - <br />� iacint s Phone: <br /> w 18c.Signature ofAnernate Facility(Dr Gelreraba) <br /> z tu�nth Day Year <br /> 19.Hazi rdous ftle Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,acid recycling 5ysteru5) <br /> 1 <br /> A H070 2 H1413. 4. <br /> 7 <br /> E20 *ate3 Facility Owner or Operator Certification of receipt of hazardous matelots covered by�manifest ezeept as noted in,ltem 18a <br /> y Name <br /> ft Signa <br /> ,A A {/ Mumn Uay Year <br />