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RECEIVED BY SJCEHD (EF) on 11/27/2019 <br /> Please print or type. 111111111111111 <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.BE en Response Phone 4.Manifest Track' Numb�jr C <br /> WASTE MANIFEST CAL500379505 1 8735172669 012 6Z 859 F L E <br /> 5.Generators Name and Mailing Address Generator's Site Address(n different than m ilin 'dress <br /> Smart & Final #403 Smart Pina�l#453 <br /> 2094643829 147 N. Wilson Way 147 N. Wilson Way <br /> Generators Phone: Stockton, CA 95205 Stockton, CA 95205 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Stericycle•-.Specialty Waste Solutions Inc <br /> pa' ame - U.S.MNSM _ <br /> 7.T er 2eD Number <br /> -L.C-N-K <br /> v_. <br /> 8.Designated FscflffyNal*,aW' '"Addra`ss Rho Chem, LLC U.S.EPA ID Numtier <br /> 425 Isis Avenue <br /> Inglewood, CA 95301 <br /> Faalitys Pfiori€..- <br /> ga, 9f f� 150 ion(Indudrrtg <br /> per Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit ar� 13.(Waste Codes <br /> HMy)D No. T Quant <br /> _. u.. , <br /> Wt./Vol. <br /> f: [ hazardous waste, liquid (Consumer i DF 55125 P 33 <br /> 14.Special Handling Instructions and Additional Information 1. 151325(State Regulated Liquids -CA) <br /> 15. GENERATOR'9/00EROR'S Cif IFICATION: t hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name;and are cassifled,packaged', <br /> marked and labeledfplacarded,and are in all respeds in proper condition for transport according to applicable intemationaland national government(regulations:Eexport s1 tpmenf and I am the'Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of flue attached"EPAAcknowledgment 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).("rf I am a small quantity nerafory is fire'. <br /> Generarors/offemrs Printed/Typed Name Signature nehe l f o al Month Day Year <br /> _j 16.International Shipments <br /> F- ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> Transporter signature(for exports only): Date leaving U,S.;_ <br /> W 17.Transporter Acknowledgment of Receipt of MaterialsLU <br /> - <br /> Transporter 1 Pdntedrr <br /> Pmt yped Name S natu <br /> Month Day Year <br /> Q. Kristo er A.lmanz 0 <br /> 4 201. <br /> Z Trans PrintedlT Name Signature Month Day- Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space19 <br /> ❑ Quanfity ❑'Type ❑Residue ❑Partial Rejection ❑Full Reocticn <br /> Manifest Reference Number: <br /> 18b.Attemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> t� <br /> Facility's Phone: <br /> Lfj 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19 Hazar us aste Report Ma <br /> to rhagement Method Codes(i2.,codes for hazardous waste treatment,disposal,and recycling syst <br /> w 1 <br />� C 2• <br /> 3. 4 <br /> Z0.Desgna I er or Opera r.Certification df ofbazardous materials coveredby, manifest exce edm l <br /> Pdrritedi I <br /> " Snafu' "> e <br /> th, <br /> rrn 8700 22asv ) Prey edltrots aseFL�. <br /> Y Pa's�-MA`N'c <br /> 3 ,,ra DEQ �l'STEM <br />