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Q � ... oo2asQaat sc' ( 1ttjV 3438W -M! <br /> Pietlse print r t tle,.(Form designed for use on elite(12-pitch) el), form Approved:OM6 No 2050-0039 <br /> UNIF,(MM HAZARDOUS, t Generator lD Number 2.Page.1'of 1.3.Emergency Response Phone 4.NfanifestTracking Number-. <br /> .WASTE MANIFEST CAC0o0397504 1 (877)577,-2669 0,02( 94 409,, <br /> 5.G;,nera(ors Name and Mailing Address rreralues Site Address Of different than mailing:address) <br /> ROSS STORE#0477 ROSS STORE#0477 <br /> 340 W KETTLEMAN LN 340 VIS KETTLEMAN LN <br /> LODI,CA 85240'(209)369=1388: l0.11,CA-95240 2093641386'. <br /> Generator's Pnonl3: <br /> 6.Trarisportirl:.ompq <br /> Y Name Q.S,'IEPA ID Number.. <br /> STERICYCLE,SPECIALTY-WASTE.SOLUTIONS INC' MNSOOQ110924 <br /> / Transporter 2 CompanyName U.S.EPA ID Number <br /> 11,15esi natedfacility Nameand Site Address U,S..EPA ID Number <br /> 21 st:,Century Environmental Management of Nevada LLC NVQ980885338 <br /> 2095 Newlands Qr._fast, . <br /> Fernley NY 89408" (775)675-2760 <br /> Facility's Phones <br /> ga: 9b U.S:DOT Description(including Proper Shipping Name,Hazard Class,ID Number, ` 10.Containers 11.Total 12.Unit 13. Waste Godes <br /> and Packing Gip(if may)) No. Type , Quantity - Wt.No1. <br /> 1 UM2810.,WASTE-TOXIC;LIQUIDS,ORGANIC,MO.S(LEAD;SILVER)6.1 PGtt <br /> 331 . 0006.: t .i 00 <br /> O X 1 DF 131 P,' -€€ <br /> [1011-1.i 0016 t <br /> 2 t1Nt993 W1#$TE FlJlMMABLE LIQUIDS,NWS.(ACETONE):3 PGII , <br /> 331. .D001 <br /> x 1 DF 10.6 <br /> 9 ).: <br /> 4. <br /> f4.Special Hans g InsYut rs WAdditional Information <br /> (f)ROSS6l�06r.E14G(Its) OSS6+1-O6-;TOXIC.LOOSEPACK(2)ROSSFLAfdM-Q6 ERg128)ROSSFLAWA-M-FLAMtAABLELOOSEPACK <br /> 15: GENERATOR'$tOFFEROR'S.CERTIFICATION: I hereby declare thatthe contents of this consignment are fully and accurately.described above by.(he proper shipping name;and are classified,packaged,° <br /> marked'and labeledlpWarded,and are in all respects in proper,condition for transport according to applicable international and nationatgovemmentai regulations.tf export shipment and I am thePrimary . <br /> Exporter,'1 certify that the contents of this ccinsignmentconfbrm to the terms of the attached;EPAAckiiowledgment of Consent. <br /> i I certify that the waste rawarization statement identified in 40 CFR 262.27(a)(if I am a large quantity g ator)or(b)(d 1 am a srriall:quantity ger>etator)is true, <br /> ratorslC torsYp ����11Jtir1 me ammre � Yearpri :. <br /> .a 6.international Shipirits - <br /> Import to U.S. EIExport from U.S. Port of entry/exit - <br /> Transporter sinure f9r eVorm only:. Gate ing U.S <br /> 17:Transporter Ad AledgmemofReceiptofMaterials <br /> UJI <br /> Transporter1PrintedrrypedName SignatureMonthDay. ear.. <br /> N. Darryl Johnson <br /> 11& 19 <br /> Z <br /> Transporter 2 Printed/Typed," rgnature ay . ear <br /> 18,Discrepancy. <br /> 18a.Discrepancy Indication Space .E Quantity. O Type" D`Residue ❑Partial Rejection ❑full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generatci) U.S.EPA ID Number <br /> a <br /> �+- <br /> Facility's Phone: <br /> LO 18c.Signature of Altemate Facility(or Generator) W Day Year <br /> Ill <br /> d <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for_hazardous waste treatment,disposal,and recycling systems) <br /> Q. 1. 2. 3 4• : <br /> H141 H141 <br /> 20•'Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the mand st.except as noted in item T8a <br /> S' nth Y <br /> EPA Form 700 2( ev.3-05) Previous a*itiosareobsolete. <br />