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jIItI'I .,I.t <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZA;t1CALW0379505 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifes <br /> t <br /> Tracking Number e C <br /> WASTE MANI1 18775772669 00 5 5 3 7 4 3 1�L C <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> S eat & Final. #403 Smart & Final#403 <br /> 2094643885 147 N. Wil,son Way 147 -N. Wilson Way <br /> Generator's Phone: Stockton CA 95405 , <br /> 6.Transporter 1 Company Name Stoakton. <br /> U.S.LOAID Number <br /> te �'c e S ec'a�.ty Waste of ti n t n;� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address General Environmental Mgt, LLC 13%S�ffA­115 NumbEL " <br /> 11855 White Rock Road <br /> Rancho Cordova, . CA 95742 <br /> Facili 's Phone:91635 0` 80 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 0� X" 1t# 266,. Waste Corrosi ve -1 iquid, bas,ic, 1DF00151 ? 1 . <br /> inorganic, n. o. sa (Sodium Hydroxide, Sodium <br /> -Hypochlorite-) 8 pG lI ERG#154 <br /> X z 1950, Waste,,Aerosols, Lflae able,.e (eaPh not 1 BR,., 14 P 214 DWI <br /> exceeding 1 L capacity)] 2. 1, ERG##1 6 <br /> 3LN19 ,3, haste FlalgUids . n.� .s�sfRA <br /> (Ethanol, Isopropyl Alcohol), 3, PG III ERG# <br /> 4. <br /> 14.Special Handling Instructions-and Additionallnformation 1.10 12 Basic Uquids) 2,P G_ 1 4 ria <br /> :i 1, 0(Flaeeable Liquids). <br /> r <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(K t am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Generator's/Offeror's Printe yped Name y <br /> -- 0 f-of -Smart 114 Fin l ' on a Year <br /> rJ 16.Intemational Shipments - W ,-. <br /> I.- <br /> -=Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter s' nature for exports only): <br /> Date leaving U.S.: <br /> W 17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 rinted/Typed Name igna ure on y ear <br /> - �, �. a ._ „ <br /> Z Transporter 2 Printed/Typed Name � a <br /> more -Day m <br /> ear <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest <br /> 18b.Alternate Facility(or Generator) Reference Number: <br /> J U.S.EPA ID Number <br /> V <br /> Q <br /> �- <br /> Facilitys Phone: <br /> W18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardqus waste treatment,disposal,and recycling systems) <br /> A 1. <br /> 2. 3. <br /> 4. <br /> 20.Desiijy�ql <br /> ted F cility Owner or Operator:Certification of receipt of hazardous materials co ed by the man'rf cept as n in 1 18a <br /> Pri yped Name Signal <br /> 1+ Da ear <br /> EPA Fo 87 � <br /> ( ev.3-05) Previous edi ions are obsolete. SIGN 7Et3 LI[TY TO€1E i0R S F REQ iR <br /> 87 -!-c _l v3 :CAL,20080121. 540020778 (34087979A M <br /> 0 ? f+ QTb1AT 1-y <br />